in  tije  Citp  oi  jBleto  porfe        ^ 
College  of  Ptpsiiciansi  anb  ^urgeonsJ 


^.ibrarp 


^      THE 


Q  LiBRARiES  ::; 


HEALTH 
SCIENCES 
LIBRARY 


CESAREAN  SECTION 


CESAREAN   SECTION 


BY 


FRANKLIN   S.  NEWELL,  A.B.,   M.D. 

PROFESSOR    OF    CLINICAL   OBSTETRICS,    HARVARD    UNIVERSITY; 

OBSTETRICIAN,    MASSACHUSETTS    GENERAL    HOSPITAL;    VISITING 

OBSTETRICIAN,   BOSTON   LYING-IN   HOSPITAL 


GYNECOLOGICAL  AND  OBSTETRICAL  MONOGRAPHS 


WITH  FIFTY-THREE  ILLUSTRATIONS 


D.  APPLETON  AND   COMPANY 

NEW  YORK  LONDON 

1921 


COPVBJGHT,    Ig21,   BY 

D,  APPLETON  AND  COMPANY 


101 


PRINTED  IN  THE  UNITED  STATES  OF  AMERICA 


PREFACE 

The  reason  for  this  book  lies  in  the  fact  that,  while  it  is  recognized 
among  well  trained  obstetricians  that  Cesarean  section  is  one  of  the  most 
valuable  operations  yet  devised  both  as  a  life  and  health  saving  procedure 
for  both  mother  and  child,  the  results  which  follow  the  operation  as  it 
is  performed  in  general  practice  are  such  as  to  suggest  that  comparatively 
few  surgeons  give  their  patients  sufficient  study  to  determine  whether 
delivery  is  best  to  be  accomplished  by  Cesarean  section  or  by  some  other 
means. 

The  purpose  of  this  volume  is  to  bring  out  definitely  in  the  first  place 
the  indications  and  contra-indications  for  the  operation,  as  well  as  the 
methods  of  operation,  in  the  hope  that  it  may  have  some  influence  in 
diminishing  the  prevalent  abuse  of  one  of  the  most  valuable  obstetric 
procedures.  I  believe  at  the  present  time  that  Cesarean  section  is  so 
commonly  performed  on  patients  who  are  improper  risks  for  one  reason 
or  another  that  obstetric  mortality  and  morbidity  are  increased  rather 
than  diminished  by  the  operation,  and  that  the  true  value  of  the  operation 
can  be  appreciated  only  when  it  is  applied  tO'  properly  selected  patients 

by  competent  operators. 

Franklin  S.    Newell 
Boston 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/cesareansection08newe 


CONTENTS 

CHAPTER  PAGE 

I.    History i 

Definition  of  cesarean  section,  i — Origin  of  the  name,  i — Antiquity  of 
the  operation,  2 — Operations  in  uncivilized  races,  2 — Authentic  history 
of  the  operation,  2 — Four  periods :  first  period,  previous  to  1500,  3 — 
Second  period :  1500  to  1876,  3 — Third  period :  1876  to  1907,  5 — Fourth 
period :  1907  to  date,  7 — Early  operations,  technic  and  mortality,  4^  5 
— Porro  operations,  amputation  of  uterus,  5 — Sanger  operation,  use 
of  sutures  and  preservation  of  uterus,  6^Extraperitoneal  modifica- 
tions, 7,  sq. 

II.    Indications  for  Cesarean   Section 11 

Cesarean  section  originally  an  operation  of  last  resort,  11 — Results 
better,  the  earlier  in  labor  it  is  performed,  11 — A  much  abused  pro- 
cedure, 12 — Not  without  danger,  12 — Bad  results  if  performed  on 
improper  cases,  13 — Indicated  only  in  cases  in  which  pelvic  delivery 
is  dangerous,  13 — Indications  in  pre-aseptic  days,  13 — Increased  safety 
under  modern  conditions,  13 — Modern  indications,  14 — Results  not 
ideal  under  best  conditions,  14 — Indications,  15 — Pelvic  contraction,  17 
— Absolute  and  relative  indications,  17,  18 — Examination  of  the  pelvis 
in  doubtful  cases,  20 — Palpation  of  pelvic  cavity  under  anesthesia,  22 
— Estimation  of  fetal  head,  25 — Probable  character  of  labor,  26 — 
Dilatation  of  cervix,  26 — Molding  power  of  fetal  head,  28 — Modified 
trial  of  labor  in  doubtful  cases,  29 — Probable  effect  of  labor  on  the 
patient  in  cases  of  contracted  pelvis,  30 — Cardiac  conditions  compli- 
cating in  contracted  pelvis,  31 — Pelves  with  a  true  conjugate  of  9 
cm.  or  over,  32 — Contraction  of  the  pelvic  outlet,  34. 

HI.    Other  Pelvic  Indications 40 

Kyphotic  pelvis,  40 — Spondylolisthetic  pelvis,  42 — Coxalgic  pelvis,  43 — 
Obliquely  contracted  pelvis,  45 — Transversely  contracted  pelvis,  47 — 
Osteomalacic  pelvis,  47 — Pelvic  exostoses,  49 — Tumors  of  the  pelvis, 
49 — Old  pelvic  fractures,  49. 

IV.    Non-Pelvic  Indications  for  Cesarean  Section 52 

Cesarean  section  in  pelvic  obstruction  not  due  to  the  pelvis  itself,  52 — 
Tumors  of  the  uterus,  53 — Fibromyomata,  53 — Carcinoma  of  the 
cervix,  54 — Tumors  of  other  organs,  55 — Ovarian  tumors,  55 — Pro- 
lapse of  kidney  or  spleen,  57 — Echinococcus  cysts,  57 — Tumors  of 
bladder,  57 — Tumors  of  rectum,  57 — Atresia  of  birth  canal,  57 — 
Vulva,  57 — Vagina,  58 — Cervix,  58 — Uterine  displacements,  59 — 
Dystocia  following  operation  for  uterine  displacements,  60 — Cesarean 
section  on  account  of  previous  incision  of  uterus,  62. 

V.    Other  Indications 67 

Cesarean  section  in  toxemia  of  pregnancy,  67 — Separation  of  the  pla- 
centa, 71 — Cardiac  disease,  74 — Poor  physical  equipment,  77 — Poor 
nervous  equipment,  77 — Elderly  primiparae,  78 — After  operations  for 
repair  of  previous  injury,  79 — Malpositions  of  fetus,  breech,  face, 
transverse,  80 — Abdominal  abortion,  82. 


viii  CONTENTS 

CHAPTER  PAGE 

VI.  Contra-Indications  to  the  Elective  Cesarean  Section  ....  85 
Definition  of  elective  cesarean  section,  85 — The  absolute  indication,  85— 
The  elective  operation  vs.  operation  at  the  time  of  election,  85 — Best 
time  for  operation,  85 — Fundamental  principles  governing  the  opera- 
tion, 86^Conditions  increasing  danger  to  maternal  life,  86 — Infec- 
tion, 87— Exhaustion,  89 — Attempts  at  pelvic  delivery,  89 — Infectious 
diseases,  90 — Surrounding  conditions,  91 — Training  of  the  attendant 
in  relation  to  choice  of  operation,  92. 

VII.    Preparations  for  Operation 94 

Time  of  operation,  94— Necessity  for  prenatal  study,  95 — Advantages  of 
operation  at  a  fixed  date,  95— Operation  before  completion  of  preg- 
nancy, 95 — Heart  conditions,  96-;-Toxemia,  96 — Hemorrhage,  97 — Pre- 
cautions, if  test  of  labor  is  given,  97 — Preparation  of  patient  for 
operation,  97 — Fixed  date,  97 — Emergency,  98 — Preparation  of  field 
of  operation,  98 — The  operator  and  assistants,  99 — Instruments  and 
sutures,  100 — Dressings,  loi — Choice  of  anesthetic,  102 — General,  102 — 
Local,  103 — Spinal,  104. 

VIII.    Operation  106 

The  classical  cesarean  section,  106 — Use  of  oxytocics,  107— Abdominal 
incision,  107 — High,  108 — Low,  108 — Technic  of  operation,  109— Ques- 
tion of  haste,  109 — Protection  of  peritoneal  cavity,  109 — Uterine  in- 
cision, no — Extraction  of  child  and  placenta,  no — Suture  of  uterine 
incision,  113 — Peritoneal  toilet,  113 — Precautions  against  postpartum 
hemorrhage,  113 — Closure  of  abdominal  wound,  113 — Transverse 
fundal  incision  of  uterus,  113 — Advantages,  114 — Disadvantages,  116— 
Gastric  lavage  to  diminish  postoperative  vomiting,  117. 

IX.    After  Care 119 

Relief  of  pain,  119 — Thirst,  120 — Diet,  120 — Care  of  bladder,  121 — 
Bowels,  121 — Intestinal  distention,  122 — Lochia,  123 — ^Treatment  of 
returned  lochia,  123 — Antiseptic  precautions,  124 — Vaginal  douches 
contra-indicated,  124 — Lactation  and  nursing,  124 — Temperature,  125 
— Pulse,  126. 

X.    Complications  of  the  Convalescence 127 

Acute  dilatation  of  stomach,  127 — Pneumonia,  129-— Embolism,  130 — 
Septic  complications,  130 — Infection  of  the  uterine  wound,  131 — 
Cystitis,  131  —  Thrombophlebitis,  131  —  Peritonitis,  134  —  Appendi- 
citis, 138. 

XI.    Sterilization  of  the  Patient  at  the  Time  of  Operation   ....    139 
Sterilization  sometimes  justifiable,   139 — To  avoid  repeated  operations, 
139 — Not  advisable  at  first  operation  unless  organic  disease  contra- 
indicates  future  pregnancies,  140 — In  cardiac  diseases,  140 — In  chronic 
nephritis,  141 — Methods  of  sterilization,  142. 

XII.    Special  Methods  of  Operation •    .    144 

Porro  operation,  144 — Supravaginal  hysterectomy,  144 — Indications,  145 
— Technic  of  the  Porro  operation,  146 — Technic  of  supravaginal 
hysterectomy,  146 — Panhysterectomy,  149. 

XIII.    Extra-  and  Transperitoneal  Cesarean    Sections       .       .        .       .        151 
History  of  extraperitoneal  cesarean  section,  151 — Unnecessary  in  clean 
cases,  152 — Not  efficient  in  frankly  infected  cases,  153 — ^Indications  for 
extraperitoneal   operations,    154 — Methods   of   operation,    155 — Extra- 


CONTENTS  ix 

CHAPTER  PACE 

peritoneal  operation,  157 — Kiistner's  modification,  157 — Latzko's  opera- 
tion, 161 — Transperitoneal  operation,  162 — Hirst's  modification,  167. 

XIV.     Principles   Governing  Choice  of  Operation 173 

Objects  to  be  sought  in  any  obstetric  case,  173 — Prenatal  study  of  pa- 
tient and  choice  of  method  of  delivery  best  fitted  for  individual,  174 
— Age  of  patient,  178 — Size  of  pelvis,  179 — Size  of  baby,  183 — Ad- 
vantages to  given  patient  of  various  methods  of  delivery,  185 — Pri- 
mary operation,  186 — Operation  after  modified  test  of  labor,  187. 

XV.    Vaginal  Cesarean  Section igo 

Vaginal  hysterotomy  better  name  for  operation,  190— Indications,  igo — 
First  three  months  of  pregnancy,  191 — Second  three  months,  192 — Last 
three  months,  192 — Technic  of  operation,  193. 


ILLUSTRATIONS 


FIGURE 

1.  Pelvimeter        ......... 

2.  Measuring  distance  between  anterior  superior  spines 

3.  Measuring  external  conjugate  diameter     .... 

4.  Measuring  diagonal  conjugate  diameter     .... 

5.  Measuring  diagonal  conjugate  diameter  on  the  fingers 

6.  7.  Variation  in  diagonal  conjugate  diameter  in  accordance  with  height 

and  inclination  of  symphysis  pubis       .... 

8.  Palpating  pubic  arch        ....... 

9.  Measuring  transverse  diameter  at  outlet     .... 

10.     Measurement     of     anteroposterior     diameter     at     outlet     (Williams 
method)       ......... 

11,12.     Importance   of   anterior   and   posterior   sagittal   diameters:    spon 
taneous   delivery  ....... 

13,  14.     Importance     of      anterior      and     posterior     sagittal      diameters 
cesarean    section         ....... 

15.  Measurement    of    anterior    and    posterior    sagittal    diameters    with 

Thorns'  pelvimeter       ....... 

16.  Dorsolumbar  kyphosis:  longitudinal  section 

17.  Pelvis  obtecta     ......... 

18.  Spondylolisthesis       ........ 

19.  Woman  with  spondylolisthesis  ...... 

20.  Coxalgic  pelvis  with  ankylosed  femur       .... 

21.  Pelvis  obliquely  contracted  from  tension  of  dislocated  femur 

22.  Pelvis  obliquely  contracted  (from  front)     .... 

23.  Pelvis  obliquely  contracted  (from  behind) 

24.  Pelvis  transversely  contracted  ...... 

25.  Osteomalacic  pelvis  (from  above)     ..... 

26.  Osteomalacic  pelvis  (from  above) 

27.  Dystocia  resulting  from  ovarian  cyst        .... 

28.  Dystocia  resulting  from  ventrosuspension  .... 

29.  Conservative  cesarean  section  (I)      . 

30.  Conservative  cesarean  section  (II)    . 

31.  Conservative  cesarean  section  (III)   ..... 

32.  Conservative  cesarean  section  (IV)   ..... 

33.  Cesarean  section  with  supravaginal  hysterectomy     . 


PAGE 
17 
18 

19 

20 
21 

22 

23 

24 

25 

34 

35 

36 
41 
42 
42 

43 
44 
45 
46 
46 

47 

48 

48 

56 

61 

III 

112 

114 

115 

147 


Xll 


ILLUSTRATIONS 


34.  Cesarean  section  with  supravaginal  hysterectomy 

35.  Kiistner's  operation  (I)    . 

36.  Kiistner's  operation  (II) 

37.  Kiistner's  operation  (III) 

38.  Kiistner's  operation  (IV) 

39.  Latzko's  operation    (I) 

40.  Latzko's  operation  (II) 

41.  Latzko's  operation  (III) 

42.  Latzko's  operation  (IV) 

43.  Latzko's  operation  (V) 

44.  Hirst's  operation    (I) 

45.  Hirst's  operation   (II) 

46.  Hirst's  operation    (III) 

47.  Hirst's  operation    (IV) 

48.  Vaginal  hysterotomy   (I). 

49.  Vaginal  hysterotomy   (II) 

50.  Vaginal  hysterectomy   (III) 

51.  Vaginal  hysterotomy    (IV) 

52.  Vaginal  hysterotomy    (V) 
53-  Vaginal  hysterectomy    (VI) 


PAGE 
148 

160 
161 
162 
163 
164 

166 
167 
168 
169 
170 
194 

196 
197 
198 
199 


CESAREAN  SECTION 


CESAREAN  SECTION 


CHAPTER  I 

HISTORY 

Definition  of  Cesarean  Section — Origin  of  the  Name — Antiquity  of  the  Operation — 
Operations  in  Uncivilized  Races — Authentic  History  of  the  Operation — Four 
Periods:  i.  Previous  to  1500;  2.  1500-1876;  3.  1876-1907;  4.  1907 — Early  Opera- 
tions, Technic  and  Mortahty — Porro  Operations,  Amputation  of  Uterus — Sanger 
Operation,  Use  of  Sutures  and  Preservation  of  Uterus — Extraperitoneal 
Modifications — Bibliography. 

Under  the  term  cesarean  section,  or  laparohysterotomy,  are  included 
the  various  operations  by  means  of  which  the  dehvery  of  the  child  is 
effected  through  an  incision  in  the  abdominal  and  uterine  walls.  The 
name  is  not  properly  applied  to  operations  for  the  removal  of  the  child 
from  the  abdominal  cavity  after  rupture  of  the  uterus  or  for  the  delivery 
of  a  child  in  cases  of  abdominal  pregnancy,  but  is  restricted  to  the 
abdominal  delivery  of  a  child  normally  situated  in  utero. 

The  origin  of  the  term  "cesarean"  is  more  or  less  obscure.  For  a  long 
time  it  was  popularly  believed  that  Julius  Caesar  was  brought  into  the 
world  by  this  means  and  that  he  obtained  his  name  from  the  operation 
by  which  his  birth  was  accomplished  (a  cesa  matris  uteri).  It  is  almost 
certain,  however,  that  this  derivation  of  the  name  is  incorrect,  since  his 
mother,  Julia,  lived  many  years  after  his  birth,  as  is  proven  by  his  letters 
to  her,  and  furthermore,  at  the  time  when  Caesar  lived  the  operation  is 
not  known  to  have  been  performed  on  the  living  woman,  at  least  in 
countries  under  Roman  rule.  It  is  also  a  fact  that  Julius  Caesar  was  not 
the  first  of  his  name,  since  there  is  mention  in  Roman  history  of  a  priest 
named  Caesar,  who  lived  at  a  considerably  earlier  period,  which  proves 
at  least  that  the  name  did  not  owe  its  origin  to  the  method  of  Caesar's 
birth. 

Two  other  plausible  explanations  for  the  origin  of  the  name  have 
been  given :  first,  that  the  term  is  derived  from  the  latin  verb  cedere 
(to  cut),  and,  therefore,  that  it  simply  implies  delivery  by  means  of 
cutting,  which  is,  of  course,  possible,  since  children  delivered  from  dead 
mothers  by  abdominal  section  were  known  as  "cesones."     It  seems  more 

I 


2  CESAREAN  SECTION 

probable,  however,  that  the  following  explanation  is  the  correct  one. 
In  715  B.  C.  Numa  Pompilius,  the  king  of  Rome,  codified  the  Roman 
law,  and  in  this  lex  regia,  as  it  was  called,  it  was  ordered  that  abdominal 
section  should  be  performed  on  all  women  who  died  when  far  advanced 
in  pregnancy,  even  in  cases  when  there  was  no  chance  of  survival  for 
the  child,  so  that  the  mother  and  child  might  be  buried  separately.  The 
lex  regia  became  the  lex  cesarea  under  the  rule  of  the  emperors  and  the 
operation  became  known  as  the  cesarean  operation. 

The  antiquity  of  the  operation  on  the  dead  is  thus  clearly  established 
under  early  Roman  civilization,  and  there  is  some  slight  evidence  that 
it  may  have  been  known  to  the  early  Egyptians.  Furthermore,  it  is  re- 
ferred to  in  the  myths  and  folk  lore  of  the  early  European  races  who 
were  much  less  civilized,  although  not  in  terms  which  justify  any  belief 
that  it  was  performed  on  the  living  woman.  It  is,  therefore,  fair  to  as- 
sume that  a  large  proportion,  if  not  all,  of  the  early  races,  recognized 
the  propriety  of  cesarean  section  on  women  who  died  late  in  pregnancy, 
in  the  hope  of  preserving  a  fetal  life  which  might  be  of  value  to  the 
community. 

Cesarean  section  on  the  living  is  of  more  recent  date,  but  its  be- 
ginnings are  utterly  obscure.  It  is  possible,  however,  that  it  was  known 
to  certain  of  the  early  races.  Various  authorities  are  inclined  to  believe 
that  certain  passages  in  the  Talmud  have  reference  to  the  operation  on 
the  living,  and  the  children  delivered  through  the  flanks  of  their  mothers 
were  given  the  name  "Jotze  Do  fan"  by  the  ancient  Jews,  although  there 
is  no  evidence  as  to  the  fact  of  the  mothers  surviving  the  operation  or 
that  they  were  living  when  the  operation  was  undertaken. 

Perhaps  the  strongest  suggestion  of  the  possible  early  development  of 
cesarean  section  on  the  living  among  uncivilized  peoples  is  furnished  by 
the  operation  witnessed  by  Dr.  Felkin  in  Uganda  in  1879,  performed  by 
a  native  specialist.  The  operator  evidently  possessed  distinctly  more 
knowledge  of  asepsis  than  his  civilized  confreres  of  that  period,  since 
he  washed  his  hands  and  the  field  of  operation  with  baiiana  wine  before 
operating,  instead  of  deferring  the  cleansing  of  his  hands  until  after 
operation,  as  was  more  or  less  common  in  civilized  practice  at  that  time. 
The  patient  was  anesthetized  by  being  made  drunk  with  the  same  prepa- 
ration. A  rapid  incision  of  the  abdominal  wall  and  uterus  was  done,  the 
child  removed  and  the  cord  cut.  The  placenta  was  then  removed,  the 
cervix  dilated  from  above,  and  the  uterus  was  massaged  and  compressed 
to  check  hemorrhage.  The  peritoneal  cavity  was  cleansed  of  liquor  and 
blood  by  raising  the  patient  up,  and  then  the  abdomen  was  closed  by 
means  of  pin  and  figure  of  eight  sutures.     The  wound  was  dressed 


HISTORY  3 

with  a  paste  of  crushed  herbs.  The  wound  healed  in  eleven  days,  and 
the  convalescence  was  only  slightly  febrile,  with  the  temperature  remain- 
ing under  ioi°  throughout  the  whole  puerperium.  Such  a  well  devel- 
oped technic  suggests  that  the  operation  had  been  under  development 
for  a  long  time,  and  it  seems  very  possible  that  cesarean  section  may 
have  been  practised  among  certain  barbarous  races  with  success,  perhaps 
for  centuries,  while  among  civilized  surgeons  it  remained  an  operation 
of  the  greatest  danger,  only  to  be  attempted  as  a  last  resort  after  the 
failure  of  every  other  known  expedient  to  accomplish  delivery. 

The  authentic  history  of  cesarean  section  may  be  said  to  cover  four 
periods,  the  first  extending  from  the  earliest  times  to  the  beginning  of 
the  sixteenth  century;  the  second  from  the  year  1500  to  1876,  when 
Porro  published  his  method  of  amputation  of  the  uterus  followmg 
cesarean  section;  the  third  period  begins  with  the  year  1876  and  extends 
to  1907,  and  includes  the  period  of  development  of  the  so-called  con- 
servative cesarean  operation;  and  the  fourth  period,  from  1907  to  date, 
covers  the  development  of  the  extraperitoneal  operation  in  cases  not 
considered  suitable  for  the  classical  conservative  cesarean. 

First  Period:  previous  to  1500. — During  this  period  the  operation 
was  occasionally  performed  on  women  who  had  died  during  the  latter 
part  of  pregnancy,  in  the  hope  of  obtaining  a  living  child.  There  is  no 
evidence  to  warrant  the  belief  that  the  operation  was  performed  on  living 
women  during  this  time,  at  least  in  European  races,  and  it  seems  hardly 
possible  that  so  radical  a  procedure  should  have  been  undertaken  and 
leave  no  trace  in  the  writings  of  the  times.  Several  authorities  believe 
that  certain  passages  in  the  Talmud  may  be  so  interpreted  as  to  point  to 
its  performance  on  the  living  amongst  the  Jews,  but  the  evidence  is,  to 
say  the  least,  unconvincing  and  lacking  in  authority. 

Second  Period  :  1500  to  18 f 6. — The  second  period  extends  from 
1500  to  1876.  During  this  time  the  operation  was  occasionally  per- 
formed on  the  living  as  an  operation  of  last  resort  when  all  other  means 
of  delivery  had  been  tried  and  failed,  and  the  results,  as  would  naturally 
be  expected  in  the  light  of  our  modern  experience,  were  so  appalling  that 
the  operation  was  looked  on  as  almost  sure  to  be  fatal,  until  in  1876 
Porro  described  his  operation,  which  altered  the  prognosis  very  mate- 
rially for  the  better, 

Caspar  Bauhin  (1588)  states  that  the  first  cesarean  section  upon  a 
living  woman  was  performed  in  1500,  when  Jacob  Nufer,  a  castrator  of 
pigs  at  Sigerhausen,  Switzerland,  operated  successfully  upon  his  own 
wife,  after  a  dozen  midwives  and  several  barbers  had  failed  to  deliver 
her,  and  had  given  up  the  task  as  hopeless.     Inasmuch  as  the  patient 


4  '  CESAREAN  SECTION 

subsequently  had  five  spontaneous  labors,  it  Is  fair  to  infer  that  the 
operation  was  not  a  true  cesarean  section,  but  in  all  probability  the  re- 
moval of  an  extra-uterine  child  from  the  abdominal  cavity. 

Frangois  Rousset,  in  1581,  wrote  a  monograph  on  the  subject,  in 
which  he  gave  the  histories  of  fifteen  cesarean  operations  collected  from 
various  sources.  Several  of  these  cases  were  not  authentic,  and  it  seems 
probable  that  the  majority  of  the  others  were  operations  for  advanced 
extra-uterine  pregnancy.  In  spite  of  the  fact  that  few,  if  any,  of  these 
cases  were  true  cesarean  sections,  this  treatise  had  one  great  merit,  in  that 
it  brought  the  operation  to  the  attention  of  the  medical  profession  and 
suggested  the  possibility  of  its  performance  on  the  living  woman. 

The  first  generally  accepted  cesarean  section  was  performed  in  16 10, 
by  Trautmann  of  Wittenberg,  on  a  woman  with  hernia  of  the  gravid 
uterus.  From  this  time  on,  the  operation  was  performed  from  time  to 
time  on  patients  in  whom  delivery  seemed  hopeless,  after  repeated  at- 
tempts had  been  made  by  other  methods  and  had  failed.  In  spite  of  the 
frightful  mortality  which  attended  the  operation  and  which  aroused  the 
opposition  of  many  of  the  leading  obstetricians  of  Europe,  the  operation 
gradually  gained  a  foothold  and  was  accepted  as  a  justifiable  procedure 
in  the  hopeless  cases  where  other  methods  had  failed  and  the  only  alter- 
natives were  cesarean  section  or  permitting  the  patient  to  die  undelivered. 
The  attitude  of  the  Catholic  Church  in  favoring  the  operation,  because 
it  gave  an  opportunity  for  baptism  of  the  child,  had  much  to  do  with 
the  development  of  the  operation,  and  the  operation  was  performed  with 
increasing  frequency,  although  the  results  continued  to  be  so  bad  that  it 
remained  an  operation  of  last  resort,  only  to  be  undertaken  after  the 
failure  to  effect  pelvic  delivery  by  all  known  methods,  or  in  the  rare 
cases  when  it  was  evident  that  the  pelvic  obstruction  was  so  extreme  as 
to  render  attempts  at  delivery  per  vaginam  utterly  hopeless. 

During  this  period  the  technic  of  the  operation  was  exceedingly  crude, 
which,  together  with  the  fact  that  the  operation  was  only  performed  on 
women  who  would  today  be  considered  bad,  if  not  unjustifiable,  operative 
risks,  unless  a  subsequent  hysterectomy  were  performed,  naturally  gave 
bad  results.  The  abdominal  wall  and  uterus  were  incised  and  the  child 
and  placenta  extracted.  The  contraction  and  retraction  of  the  uterine 
walls  were  relied  on  to  control  hemorrhage,  the  uterine  incision  not  being 
sutured,  and  the  uterus  was  dropped  back  into  the  abdominal  cavity  to 
act  as  a  persistent  source  of  hemorrhage  and  peritoneal  infection.  Sutures 
were  first  used  by  Lebas  in  1769,  but  did  not  come  into  general  use  until 
Sanger  published  his  article  describing  his  technic  in  1882.  The  majority 
of  the  women  died  of  hemorrhage  or  infection,  and  the  statistics  of  the 


HISTORY  5 

operation  were  so  bad  that  in  1777  it  was  almost  entirely  superseded  by 
symphyseotomy,  only  to  be  rehabilitated  at  a  later  date  when  symphy- 
seotomy fell  into  disrepute  on  account  of  the  bad  results  which  attended 
its  performance.  Few  operations  have  passed  through  such  a  dis- 
couraging early  stage,  to  become  acknowledged  as  among  the  greatest  life 
saving  procedures  of  modern  surgery. 

Kayser  (Copenhagen,  1844)  found  a  mortality  of  62  per  cent,  for 
the  previous  eighty  years.  Murphy  (London,  1862)  reported  86  per 
cent,  mortality  in  Great  Britain.  Meyer  (1867)  collected  1605  cases 
from  the  literature  with  a  mortality  of  54  per  cent.  Budin  (1876)  states 
that  not  a  single  successful  cesarean  section  was  performed  in  Paris  be- 
tween the  years  1787  and  1876,  and  Spath  (1877)  reported  a  similar 
condition  in  Vienna.  Harris  (1878)  reported  that  of  eighty  cases  oper- 
ated on  in  the  United  States  up  to  that  time,  52.5  per  cent.  died. 

Such  results  would  cause  the  permanent  abandonment  of  most  opera- 
tions, and  it  was  only  due  to  the  fact  that  an  abdominal  delivery  gave 
the  only  possible  chance  for  life  to  a  certain  number  of  unfortunate 
women,  that  the  operation  was  not  permanently  discarded.  Such  poor 
results  were  obtained  when  the  operation  was  performed  by  surgeons  that 
Harris  pointed  out  that  the  patient's  chances  of  recovery  were  better 
when  the  patient,  unable  to  endure  the  pain  of  labor  longer,  performed 
the  operation  on  herself,  or  when  the  abdomen  was  ripped  open  by  the 
horn  of  an  infuriated  bull;  and  he  collected  nine  such  cases  from  the 
literature,  with  five  recoveries,  in  contrast  to  eleven  cesarean  sections 
performed  in  the  City  of  New  York  during  the  same  period,  with  one 
recovery. 

Third  Period:  iSyd  to  iQOf. — The  third  period  began  with  the 
year  1876,  when  Porro  of  Pavia,  recognizing  that  the  greatest  risks  to 
the  patient  arose  from  hemorrhage  from  the  open  vessels  of  the  uterine 
walls  and  from  the  escape  of  infected  lochia  into  the  peritoneal  cavity, 
advised  amputation  of  the  body  of  the  uterus  and  fixation  of  the  stump 
in  the  lower  angle  of  the  abdominal  wound,  in  order  to  lessen  the  dangers 
of  hemorrhage  and  infection,  thus  avoiding  the  dangers  which  arose 
from  returning  the  unsutured,  usually  infected  uterus  to  the  abdominal 
cavity. 

This  procedure  was  followed  by  such  an  improvement  in  the  results 
of  operation  that  it  soon  became  very  popular,  and  in  1890  Harris  col- 
lected 264  operations  from  the  literature.  Amputation  of  the  pregnant 
uterus  had  been  done  on  a  case  of  multiple  fibroids  of  the  uterus  by 
Storer  of  Boston  in  1868,  or  eight  years  before  Porro  described  his 
operation.     The  result  in  this  case  was  fatal  and  the  operator  did  not 


6  •  CESAREAN  SECTION 

apparently  realize  the  importance  of  the  innovation,  as  applied  to  cases 
of  uncomplicated  cesarean  section,  and,  therefore,  the  credit  for  bringing 
it  to  the  attention  of  the  medical  world  as  a  possible  life  saving  procedure 
belongs  to  Porro,  although  he  v^as  not  the  first  to  perform  the  operation. 

Sanger,  in  1882,  revolutionized  the  operation  and  paved  the  way  for 
its  modern  development  by  calling  attention  to  the  importance  of  closing 
the  uterine  incision  by  suture,  instead  of  dropping  the  unsutured  organ 
back  into  the  abdomen,  to  be  a  source  of  danger  to  the  patient,  or  re- 
moving it  and  thus  rendering  her  sterile.  Since  Sanger's  operation  led  to 
the  preservation  of  the  uterus,  it  has  been  designated  as  the  conservative, 
in  contradistinction  to  the  Porro,  or  radical,  cesarean  section. 

The  increasing  perfection  of  surgical  technic  has  led  to  more  and 
more  satisfactory  results  for  the  conservative  operation,  until  at  the 
present  time  it  may  be  considered  as  the  ideal  operation  in  all  cases  in 
which  no  special  indication  exists,  calling  for  the  removal  of  the  uterus, 
while  the  Porro,  or  its  modifications,  is  now  reserved  for  special  cases 
which  call  for  special  treatment. 

The  Porro  operation  has  been  modified  as  the  technic  of  gynecologi- 
cal operations  has  been  improved,  and  the  classical  operation,  as 
described  by  him,  is  now  seldom  performed.  At  the  present  time  the 
common  technic  employed  in  cases  of  supravaginal  amputation  of  the 
non-pregnant  uterus  has  been  substituted  for  the  operation,  as  described 
by  Porro.  The  uterus  is  amputated  as  formerly,  but  the  cervical  stump, 
instead  of  being  fixed  in  the  lower  end  of  the  abdominal  incision,  is 
covered  by  a  flap  of  peritoneum  and.  dropped  back  into  the  abdominal 
cavity  and  the  abdominal  wound  is  closed.  This  method  gives  equally 
good  immediate  results  and  a  much  improved  ultimate  result,  the  long 
period  of  suppuration,  which  was  inevitable  under  the  original  Porro 
technic,  being  done  away  with. 

In  a  small  number  of  cases,  particularly  when  pregnancy  is  compli- 
cated by  operable  carcinoma  of  the  cervix,  a  panhysterectomy  is  per- 
formed, the  entire  uterus,  including  the  cervix,  being  removed.  This 
operation  was  first  attempted  by  Bischoff,  and  for  a  time  was  freely 
performed  as  an  improvement  over  supravaginal  amputation.  The  some- 
what increased  mortality  which  attends  its  use  has  led,  however,  to  its 
practical  abandonment,  except  in  the  comparatively  rare  cases  of  operable 
carcinoma  complicating  advanced  pregnancy,  although  it  is  still  oc- 
casionally advocated  in  cases  of  frank  uterine  infection.  It  is  probable  in 
these  cases,  however,  that  the  immediate  mortality  consequent  on  the 
more  severe  operative  procedure  will  more  than  compensate  for  the 
occasional  life  saved  by  the  removal  of  the  infected  cervix. 


HISTORY  7 

Fourth  Period:  i^o"/  to  date. — The  fourth  period  began  in  1907, 
when  Frank  of  Cologne,  who  had  become  dissatisfied  with  the  results  of 
the  conservative  cesarean  section  when  performed  on  women  frankly 
infected  prior  to  the  operation,  or  in  doubtful  cases  in  which  proper 
asepsis  had  not  been  observed  during  labor,  although  infection  was  not 
definitely  demonstrable,  reported  thirteen  cases  on  whom  he  had  oper- 
ated by  a  new  method. 

In  Frank's  operation  a  transverse  incision  was  made  through  the 
lower  abdominal  wall,  two  or  three  inches  above  the  symphysis  down 
to  the  peritoneum.  After  the  recti  muscles  were  severed,  the  peritoneum 
was  separated  from  the  bladder  and  anterior  surface  of  the  uterus  by 
gauze  dissection,  until  enough  of  the  lower  uterine  segment  was  exposed 
to  permit  of  a  sufficiently  large  incision  for  the  extraction  of  the  child. 
The  placenta  was  then  removed  and  the  uterine  and  abdominal  incisions 
closed.  By  this  method,  under  ideal  conditions,  the  whole  operation 
can  be  performed  extraperitoneally  and  the  danger  of  peritoneal  in- 
fection, which  is  very  great  in  doubtful  cases  on  whom  the  cesarean  sec- 
tion is  performed,  is  distinctly  lessened.  It  must  be  said,  however,  that 
Frank's  claim  that  the  operation  is  safe,  when  the  conservative  operation 
is  absolutely  contra-indicated,  has  not  stood  the  test  of  time,  and  that 
the  results  of  the  operation  have  not  been  as  universally  successful  as  he 
predicted,  as  is  shown  by  the  fact  that  the  operation  has  been  variously 
modified,  some  twenty  different  procedures  to  obtain  the  same  result 
having  been  published  in  the  twelve  years  since  the  operation  was  first 
described  by  him. 

Available  statistics  would  seem  to  show  that  in  uninfected  cases  the 
conservative  cesarean  is  at  least  as  good  an  operation  for  both  mother 
and  child,  since  the  difficulty  of  technic  and  the  increased  time  required 
for  the  extraperitoneal  operation  render  it  relatively  unsatisfactory 
for  clean  cases.  Furthermore,  even  in  frankly  infected  cases,  it  is  yet 
to  be  proved  that  extraperitoneal  section  gives  better  results  than  delivery 
of  the  uterus  from  the  abdomen  before  opening,  followed  by  partial 
or  total  hysterectomy,  in  spite  of  the  increase  in  operative  shock  in  the 
latter  operation.  The  only  advantage  lies  in  the  preservation  of  the 
uterus  for  future  childbearing,  and  in  frankly  infected  cases  this  is  more 
than  made  up  for  by  the  mortality  from  puerperal  infection  due  to  the 
retention  of  the  infected  uterus.  It  is,  therefore,  in  the  cases  in  which 
infection  is  suspected,  but  not  proven,  that  the  operation  is  indicated, 
and  not  in  either  the  clean  or  definitely  infected  cases,  it  being  unneces- 
sary in  the  former  group  and  inadequate  in  the  latter. 

Frank's  operation  was  enthusiastically  received  in  Germany,  but  its 


8  CESAREAN  SECTION 

early  promise  was  not  fulfilled.  It  was  found  in  many  cases,  either  that 
the  peritoneum  could  not  be  separated  from  the  underlying  organs,  or 
that  it  was  torn  during  the  attempt  at  separation,  thus  nullifying  the 
supposed  advantage  of  the  operation  from  not  opening  the  peritoneal 
cavity.  In  other  cases  the  bladder  was  injured  or  extensive  suppuration 
of  the  pelvic  connective  tissue  resulted,  so  that  the  morbidity  was  high, 
and  the  mortality,  while  less  than  that  obtained  when  the  conservative 
operation  was  performed  on  infected  cases  and  the  uterus  dropped  back 
to  act  as  a  source  of  infection  to  the  peritoneal  cavity,  was  no  lower 
than,  if  as  low  as,  that  obtained  by  hysterectomy. 

Not  satisfied  with  this  showing,  Latzko,  Sellheim  and  other  operators 
modified  the  operation,  converting  the  so-called  suprasymphyseal,  extra- 
peritoneal operation  into  a  suprasymphyseal  transperitoneal  cesarean  sec- 
tion. In  this  operation  the  abdomen  is  opened  by  a  transverse  incision 
and  the  uterus  exposed,  after  which  a  transverse  incision  is  made  in  the 
peritoneal  covering  of  the  uterus  just  above  the  reflexion  over  the  blad- 
der, extending  to  the  insertions  of  the  round  ligaments  on  either  side. 
The  peritoneal  flap  is  dissected  up  for  a  short  distance  from  the  anterior 
uterine  wall  and  is  then  tightly  sutured  to  the  margins  of  the  parietal 
peritoneum.  The  lower  uterine  segment  is  now  freely  exposed  and  is 
isolated  completely  from  the  peritoneal  cavity,  thus  reducing  to  a  mini- 
mum the  danger  of  peritoneal  infection.  The  bladder  is  now  freed  by 
blunt  dissection  from  its  attachments  to  the  lower  uterine  segment,  the 
latter  is  opened  by  a  transverse  incision,  the  child  and  placenta  ex- 
tracted, and  the  wounds  are  closed. 

The  results  of  these  attempts  to  modify  Frank's  operation  proved 
only  partially  satisfactory,  and  Doderlein  attempted  to  revive  the  opera- 
tion of  laparo-elytrotomy,  which  had  been  first  suggested  in  1823,  but 
had  not  been  favorably  received  at  that  time,  although  it  had  been  rehab- 
ilitated by  Gaillard  Thomas  in  1871,  only  to  be  abandoned  in  favor  of  the 
classical  cesarean  section.  In  this  operation  a  long  oblique  incision  paral- 
lel to  Poupart's  ligament  gives  access  to  the  pelvic  connective  tissue  and 
the  lateral  aspect  of  the  lower  uterine  segment,  which  is  then  incised,  and 
the  child  extracted  by  forceps.  Doderlein  reported  thirty-two  cases  in 
191 1  on  whom  he  had  performed  this  operation,  but  has  discarded  it 
since  that  time  on  account  of  certain  very  obvious  disadvantages.  Even 
in  clean  cases  the  healing  of  the  wound  proved  complicated,  and  drainage 
was  always  necessary.  In  infected  cases  the  almost  sure  infection  of  the 
pelvic  connective  tissue  rendered  a  prolonged  suppurative  process  in- 
evitable and  the  patient  only  recovered,  if  at  all,  after  a  long,  tedious 


HISTORY  9 

convalescence.     The  operation  thus  proved  of  no  value  in  the  very  class 
of  case  for  which  it  was  primarily  recommended. 

Kronig  was  not  satisfied  with  any  of  these  modifications  and  claimed 
that  their  principal  advantage  lay,  not  in  avoiding  the  peritoneal  cavity, 
but  in  the  fact  that  the  uterine  incision  was  in  the  thin  lower  segment, , 
instead  of  in  the  thick  contractile  portion  of  the  uterus.  In  the  operation, 
as  described  by  him,  the  abdomen  is  opened  either  by  a  longitudinal  or 
transverse  incision.  The  visceral  peritoneum  is  then  incised  at  the  vesico- 
uterine reflexion,  and  the  bladder  is  freely  separated  from  the  lower 
uterine  segment.  After  the  lower  uterine  segment  is  freely  exposed,  it  is 
opened  by  means  of  a  longitudinal  median  incision,  and  the  child  is 
extracted  by  forceps.  The  placenta  is  then  removed  and  the  uterine 
incision  closed.  The  operation  is  completed  by  drawing  the  bladder 
back  into  place,  and  its  peritoneal  covering  is  sutured  to  the  flap  dissected 
up  from  the  uterus  in  such  a  manner  as  to  bury  completely  the  entire 
uterine  incision. 

In  19 1 5  KiJstner  reviewed  the  whole  subject  most  carefully  and  re- 
ported his  own  modification,  based  on  a  personal  experience  of  112 
operations.  Up  to  the  present  time  this  operation  seems  to  hold  out  a 
greater  promise  of  success  than  any  of  the  other  modifications  which 
have  been  suggested  by  the  ingenuity  of  certain  American  surgeons,  but 
the  question  is  still  sub  judice  whether  any  extraperitoneal  operation  is 
properly  to  be  considered  in  any  case  in  which  the  patient  is  believed 
to  be  frankly  infected,  hysterectomy  being  the  most  satisfactory  pro- 
cedure under  such  conditions.  If  further  experience  proves  this  to  be 
the  case  the  field  for  the  employment  of  the  extraperitoneal  methods 
would  seem  to  be  limited  to  cases  in  which  it  is  at  least  doubtful  whether 
the  uterus  is  infected,  the  great  majority  of  whom  will  recover  if  operated 
on  by  the  conservative  method.  It  is,  however,  probable  if  the  peritoneal 
cavity  is  protected  against  contamination  in  these  cases  by  the  adoption 
of  one  of  the  extraperitoneal  operations,  that  the  convalescence  will  be 
more  comfortable,  owing  to  the  diminution  of  abdominal  distention, 
since  the  uterus  is  often  infected  by  an  organism  of  low  virulence,  the 
introduction  of  which  into  the  peritoneal  cavity  will  interfere  with  the 
smoothness  and  comfort  of  convalescence,  although  perhaps  it  may  not 
prove  dangerous  to  life. 

At  the  present  time  some  authors,  notably  DeLee,  are  urging  the 
abandonment  of  the  classical  section  in  favor  of  an  extraperitoneal 
operation,  even  in  clean  cases,  and  claim  improved  results,  at  least  in 
the  comfort  of  the  patient.  It  is  still  too  early  to  pass  on  the  justice  of 
their  claims,  but  my  own  experience  with  the  classical  operation,  when 


id  CESAREAN  SECTION 

performed  on  healthy  women  under  ideal  conditions,  leads  me  to  believe 
that  the  extraperitoneal  method  has  few,  if  any,  advantages  in  such  cases 
and  is  a  more  difficult  surgical  procedure.  The  results  of  any  operation 
on  unfit  patients  must  be  relatively  unsatisfactory,  to  say  the  least,  and 
it  is  possible  that  future  experience  will  demonstrate  that  cesarean  section 
by  one  of  the  extraperitoneal  methods  will  prove  the  most  satisfactory 
operation  on  all  patients  whose  powers  of  resistance  are  below  par  from 
any  cause,  even  though  no  infection  is  present.  It  is  also  admitted,  even 
by  the  most  ardent  advocates  of  the  extraperitoneal  operation,  that  when 
operative  speed  is  an  object,  as  for  instance  in  patients  with  profuse  bleed- 
ing, or  when  the  child  is  known  to  be  in  a  precarious  condition,  the  con- 
servative operation  is  preferable,  as  it  involves  much  less  loss  of  time, 
a  factor  which  is  of  great  importance  under  these  conditions. 

LITEEATUEE 

Bauhin.     vcTTepoTOfMOTOKLa  Fr.  Rousseti.     Basle,  1588. 

BuDiN.     In  Tarnier  et  Budin's  Traite  de  I'art  des  accouchements.     1901. 

iv,  495- 
Davis,  E.  P.     The  Present  Status  of  Cesarean  Section.     Am.  Jr.  Obst. 

1913.     V.  68. 
Frank,     tiber  den  Subkutanen  Symphysenschnitt.     Monschr.  f.  Gebh. 

u.  Gyn.  1 910.    32  :  680. 
Harris.     Remarks  on  the  Caesarean  Operation.     Am.  Jr.  Obst.      1879. 

1 1  :  620. 
Kayser,  C.  J.  H.    De  eventu  sectionis  caesareae  dissert.    Havniae,  1841. 
Kronig.   Transperitonealer  Cervicaler  Kaiserschnitt.     In  Kronig-Doder- 

lein's  Op.  Gynak.     1912.     P.  879. 
KiJSTNER,  O.     Der  Abdominale  Kaiserschnitt.     Wiesbaden,  191 5. 
Murphy,  E.  W.     Lectures  on  Midwifery.     London,  1862. 
RoussET,  F.    Traite  nouveau  de  I'hysterotomotokie,  ou  I'enfantement 

cesarien.     Paris,  1581. 
RouTH.     On  Caesarean  Section  in  the  United  Kingdom.     Jr.  Obst.  Gyn. 

Brit.  Emp.     191 1.  19  :  1-233. 
Spath,  J.     Compendium  der  Geburtskunde.     Erlangen,  1857. 
Sanger.     Der  Kaiserschnitt  bei  Uterusmyomen.    Leipzig,  1882. 
Thomas,  T.  G.     Gastro-elytrotomy :  a  Substitute  for  the  Caesarean  Sec- 
tion.   Am.  Jr.  Obst.     1871.    3  :  125. 
Veit,   J.      Der  Kaiserschnitt  in  Moderner   Beleuchtung.      Sam.    Klin. 

Vortr. :  Gyn.  No.  1 89.      1 909. 
Young,  E.  B.    Curiosities  of  Caesarean  Section.    Am.  Gyn.  Ped.  1903. 


CHAPTER  II 

INDICATIONS  FOR  CESAREAN  SECTION 

Cesarean  Section  Originally  an  Operation  of  Last  Resort — Results  Better,  the  Earlier 
in  Labor  it  is  Performed — A  Much  Abused  Procedure — Not  Without  Danger — 
Bad  Results  if  Performed  on  Improper  Cases — Indicated  Only  in  Cases  in  Which 
Pelvic  Delivery  is  Dangerous — Indications  in  Pre-aseptic  Days — Increased  Safety 
Under  Modern  Conditions — Modern  Indications — Results  Not  Ideal  Under  Best 
Conditions — Indications — Pelvic  Contraction — Absolute  and  Relative  Indications — 
Examination  of  the  Pelvis  in  Doubtful  Cases — Palpation  of  Pelvic  Cavity  Under 
Anesthesia — Estimation  of  Fetal  Head — Probable  Character  of  Labor — ^Dilata- 
tion of  Cervix — Molding  Power  of  Fetal  Head — Modified  Trial  of  Labor  in 
Doubtful  Cases — Probable  Effect  of  Labor  on  the  Patient  in  Cases  of  Contracted 
Pelvis — Cardiac  Conditions  Complicating  Labor  in  Contracted  Pelvis — Pelves 
with  a  True  Conjugate  of  9  cm.  or  Over — Contraction  of  the  Pelvic  Outlet — 
Bibliography. 

As  was  stated  in  the  preceding  chapter,  cesarean  section  was  originally 
employed  only  as  an  operation  of  last  resort  when  no  other  means  of 
delivery  was  possible,  and  was  seldom  or  never  resorted  to,  except  in 
cases  in  which  pelvic  delivery  had  been  repeatedly  attempted  and  it  wa^ 
felt  that  the  only  hope  of  saving  the  patient  lay  in  cesarean  section.  The 
results  were  exceedingly  bad.  With  the  advent  of  aseptic  surgery  and 
the  rhodification  of  the  technic  of  the  operation  by  Sanger,  the  results, 
even  in  apparently  desperate  cases,  showed  a  marked  improvement, 
especially  in  the  class  of  case  in  which  delivery  of  the  living  child  was 
recognized  as  impossible  comparatively  early  in  labor,  and  the  operation 
was  therefore  undertaken  before  the  patient  was  exhausted  by  prolonged 
labor  or  infected  by  repeated  manipulation.  The  increased  success  which 
has  attended  the  performance  of  cesarean  section  as  an  operation  of 
election,  instead  of  as  an  operation  of  last  resort,  has  led  to  its  employ- 
ment in  many  cases,  to  the  exclusion  of  methods  of  delivery  better 
suited  to  the  needs  of  the  given  patient,  until  at  the  present  time  it  is  the 
most  abused  obstetric  operation,  being  performed  by  comparatively  un- 
trained surgeons  on  patients  who  present  no  real  indication  for  it,  under 
conditions  which  render  it  an  exceedingly  dangerous  procedure.  It  is 
not  at  all  unusual  at  the  present  time  to  see  patients  who  have  been  sub- 
jected to  cesarean  section  for  no  apparent  reason,  as  far  as  physical 
examination  shows,  and  the  only  logical  conclusion  seems  to  be  that  the 
operative  indication  has  been  a  slow,  though  normal,  labor,  which  the 

II 


12  CESAREAN  SECTION 

attendant  has  hastened  to  end  in  the  manner  easiest  for  himself,  though 
often  not  best  for  the  patient.  The  increasing  safety  of  abdominal 
surgery,  as  modern  asepsis  has  developed,  combined  with  the  fact  that 
the  operation  is  much  easier  to  perform  than  any  but  the  easiest  obstetric 
operations,  has  caused  a  loss  of  perspective,  and  today  there  is  no  ques- 
tion but  that  cesarean  section  is  one  of  the  most  abused  operations  in 
surgery. 

There  seems  to  be  an  impression  in  the  minds,  both  of  the  general 
medical  and  lay  public,  that  cesarean  section  is  a  perfectly  simple,  safe 
operation  which  can  always  be  guaranteed  to  give  perfect  results  under 
all  circumstances.  The  fact  that  abdominal  surgery  always  carries  with 
it  a  certain  risk  to  the  life  of  the  patient,  even  in  the  most  competent 
hands  and  under  the  best  conditions,  is  entirely  lost  sight  of,  with  the 
result  that,  instead  of  being  chosen  after  careful  consideration  as  being 
the  safest  and  best  method  of  delivery  for  the  given  patient,  cesarean 
section  is  looked  on  by  many  poorly  trained  obstetricians  and  general 
surgeons,  who  do  not  pretend  to  have  even  a  working  knowledge  of 
the  fundamental  principles  of  the  obstetric  art,  as  a  panacea  for  all 
obstetric  ills,  and  the  lives  of  many  women  are  sacrificed  every  year  on 
account  of  this  disregard  for  the  interests  of  the  patient,  which  results 
in  the  performance  of  many  operations  absolutely  unjustifiable  under 
the  conditions  present  in  the  given  case. 

About  three  years  ago  my  attention  was  called  to  the  results  of 
cesarean  section  in  one  of  the  smaller  cities  near  Boston,  and  this  led 
to  a  careful  investigation  of  the  results  in  several  other  communities, 
with  the  result  that  I  am  convinced  that  cesarean  section,  as  performed 
by  the  local  operators  in  small  communities  for  the  indications  furnished 
by  the  local  practitioner  of  obstetrics,  is  one  of  the  most  fatal  of  surgical 
operations.  Even  in  the  best  hands  under  good  surgical  conditions,  an 
occasional  patient,  who  has  not  been  in  labor  for  more  than  a  few  hours 
and  who  has  never  been  subjected  to  a  vaginal  examination,  will  become 
infected  and  die  of  peritonitis,  infection  apparently  taking  place  in  the 
uterine  wound  by  extension  from  the  vagina.  When,  however,  the 
operation  is  performed  late  in  labor,  after  many  vaginal  examinations,  or 
after  attempted  vaginal  delivery,  the  results,  as  would  be  expected,  are 
much  worse,  and  the  operation  should  only  be  considered,  under  such 
circumstances,  when  no  other  means  of  delivery  seems  to  be  possible  with 
due  regard  to  the  interests  of  both  patients,  although  in  doubtful  cases 
the  interests  of  the  mother  should  be  given  precedence.  It  is,  however, 
very  common  to  hear  of  patients  who  have  been  subjected  to  operation 
after  the  ordinary  obstetric  operations  have  failed,  and  the  wonder  is 


INDICATIONS  FOR  CESAREAN  SECTION  13 

not  that  so  many  women  die,  but  that  any  recover  when  operation  is 
undertaken  on  unfavorable  cases. 

Presumably  the  ease  with  which  the  operation  can  be  performed  is 
the  prime  factor  in  the  choice  of  cesarean  section  in  improper  cases,  since, 
as  compared  with  the  ordinary  obstetric  operation,  except  perhaps  an 
easy  low  forceps,  cesarean  section  is  the  easiest  method  of  delivery  for 
the  obstetrician  and  the  safest  operation  for  the  child.  It  must  be  re- 
membered, however,  that  cesarean  section  is  an  abdominal  operation  and 
that  abdominal  surgery  is  never  entirely  without  danger;  and  further- 
more cesarean  section  is  a  distinctly  major  operation,  and  for  the  patient 
at  least  it  is  not  a  simple  procedure.  It  is  then  only  indicated  when,  on 
account  of  certain  conditions  which  are  known  to  seriously  increase  the 
risks  of  a  pelvic  delivery  to  either  mother  or  child,  or  both,  either  as 
regards  life  or  health,  a  major  surgical  procedure  is  believed  to  be  the 
safest  method  of  delivery,  and  the  risks  which  attend  its  performance 
have  been  carefully  estimated  and  given  due  weight  in  the  decision. 

In  the  pre-antiseptic  days  cesarean  section  was  considered  so  danger- 
ous an  operation  that  it  was  believed  to  be  indicated  only  in  cases  in 
which  the  delivery  of  even  a  mutilated  child  was  considered  impossible. 

Murphy,  writing  in  1862,  gives  the  following  indications  for  the 
operation : 

(i)  In  the  ovate  deformity  of  the  pelvis  when  the  conjugate  axis  is 
less  than  two  inches  (rachitis). 

(2)  In  the  cordiform  distortion  from  mollities  ossium,  when  the 
distortion  is  extreme  and  craniotomy  is  either  impracticable  or  so  difficult 
that  the  safety  of  the  mother  cannot  be  secured  (osteomalacia). 

(3)  When  tumors  are  immovable  and  so  occupy  the  pelvic  cavity 
as  to  leave  a  space  of  only  two  inches  between  the  tumor  and  the  pelvis. 

If  these  indications  were  followed  at  the  present  time,  few  cesarean 
sections  would  be  performed,  but  I  believe  that  the  maternal  death  rate 
would  be  little,  if  any,  higher  than  it  is  at  present  with  the  abuse  of 
cesarean  section  which  exists,  although  the  fetal  death  rate  would  be 
much  higher. 

The  development  of  the  aseptic  technic  in  surgery  has  made  it  pos- 
sible to  consider  the  rights  of  the  child  as  well  as  the  rights  of  the 
mother,  and  the  position  of  cesarean  section  in  modern  obstetrics  is  due 
to  the  fact  that,  under  proper  conditions  and  in  the  hands  of  a  competent 
operator,  the  risk  attached  to  it  is  little  greater  than  that  of  any  other 
abdominal  operation.  It  is,  when  performed  as  an  operation  of  election, 
a  justifiable  procedure  whenever  a  thorough  examination  demonstrates 
the  fact  that  the  child  will  be  subjected  to  serious  danger  in  case  an  at- 


14  CESAREAN  SECTION 

tempt  at  pelvic  delivery  is  made,  or  that  the  health  of  the  mother  is 
likely  to  suffer  sufficiently  seriously  from  a  pelvic  delivery  to  warrant 
the  somewhat  increased  risk  that  attends  an  abdominal  delivery. 
,  The  modern  indications  for  cesarean  section,  therefore,  may  be  said 
to  include  all  conditions  which  so  complicate  labor  as  to  seriously  threaten 
the  life  or  health  of  either  patient,  and  although  the  operation  cannot 
be  said  to  be  without  some  risk  to  the  maternal  life,  the  risk  is  a  com- 
paratively small  one  under  proper  conditions  and  may  properly  be 
assumed  for  the  sake  of  real  advantage  for  either  mother  or  child, 
though  not  for  the  convenience  of  the  attendant  or  on  account  of  the 
fact  that  he  is  not  properly  qualified  to  care  for  a  situation  which  can 
be  more  safely  dealt  with  by  some  other  method  by  a  trained  obstetric 
surgeon,  unless  it  is  impossible  to  procure  the  services  of  a  thoroughly 
qualified  operator. 

The  results  obtained  by  cesarean  section,  performed  at  the  time  of 
election  (i.e.,  before  labor  begins,  or  early  in  labor),  are  so  much  better 
than  the  results  of  the  secondary  or  late  operations  that  it  is  evident 
that  every  patient  should  be  carefully  studied  during  the  last  month  of 
pregnancy,  in  order  that  no  indication  which  may  properly  call  for 
cesarean  section  may  be  overlooked;  so  that,  if  the  operation  seems 
indicated,  it  may  be  performed  at  the  time  when  the  best  results  may 
be  expected  for  both  patients.  In  general  practice  this  precaution  is 
usually  overlooked,  and  it  is  safe  to  say  that  the  majority  of  cesarean 
operations  are  performed  at  a  time  when  the  dangers  of  the  operation 
have  been  much  increased,  either  by  a  long  test  of  labor,  by  repeated 
vaginal  examinations  often  conducted  under  doubtful  asepsis,  or  by 
ineffectual  attempts  at  pelvic  delivery.  It  may  be  urged  that  the  general 
practitioner  is  not  qualified  to  determine  the  necessity  of  the  elective 
operation,  a  fact  which  is  undoubtedly  true  in  most  cases,  since  he  has 
not  been  afforded  the  opportunity  to  acquire  the  special  knowledge  on 
which  such  a  decision  must  be  based ;  but  that  is  no  excuse,  since  it  would 
ordinarily  be  a  simple  matter  for  him  to  refer  every  primipara,  and 
every  multipara  whose  previous  obstetric  history  is  questionable,  to  a 
well  trained  obstetrician  for  an  opinion  as  to  the  proper  method  of 
delivery  in  the  given  case. 

That  the  results  of  cesarean  section  are  not  ideal,  even  in  competent 
hands,  may  be  assumed  from  the  statement  made  by  Holmes  several 
years  ago,  to  the  effect  that  any  surgeon  whose  results  showed  a  maternal 
mortality  of  more  than  five  per  cent  should  revise  the  indications  for 
which  he  operates  and  should  subject  his  operative  technic  to  the  closest 
scrutiny,  since  the  occurrence  of  so  high  a  mortality  proved  either  that 


INDICATIONS  FOR  CESAREAN  SECTION  15 

he  was  operating  on  patients  who  were  not  in  proper  condition  for 
cesarean  section,  or  that  his  aseptic  technic  was  inadequate.  The  statistics 
pubHshed  by  men  of  unquestioned  operative  ability  and  of  good  obstetric 
judgment  show  that  the  operation  is  attended  by  a  mortaHty  of  from  2 
to  4  per  cent  in  all  types  of  patients  who  are  subjected  to  the  operation, 
although  several  operators  can  show  a  series  of  100  or  more  consecutive 
cases  without  mortality.  A  fatal  result  in  a  healthy  patient  operated  on 
under  good  conditions  should  be  extremely  rare,  but  the  recognition  of 
the  benefits  of  cesarean  section  to  a  large  class  of  women  who  are 
relatively  unfit  for  childbearing  for  various  reasons,  or  in  whom  serious 
complications  are  present  which  are  sure  to  give  a  certain  proportion  of 
bad  results,  no  matter  how  they  are  cared  for,  has  resulted  in  the  wide 
adoption  of  cesarean  section  as  an  operation  for  the  delivery  of  the  unfit, 
and  naturally  surgery  on  the  unfit  carries  with  it  a  relatively  high 
mortality. 

Cesarean  section  is  indicated,  in  the  first  place,  in  patients  in  whom 
some  pelvic  obstruction  exists,  which  renders  delivery  per  vaginam,  even 
of  a  dead  and  mutilated  child,  either  impossible  or  so  dangerous  that 
an  abdominal  delivery  is  attended  by  no  greater  risks  for  the  mother 
than  a  pelvic  delivery.  This  is  admittedly  the  only  absolute  indication 
for  the  operation,  and  the  operator  who  performs  cesarean  operations 
for  other  reasons  must  be  sure  that  the  benefits  which  are  to  be  expected 
from  the  operation  for  either  mother  or  child  are  sufficient  to  warrant  a 
certain  increase  in  the  risk  to  the  maternal  life  over  what  is  to  be  ex- 
pected following  a  pelvic  delivery.  The  comparative  safety  of  abdominal 
delivery  in  properly  selected  cases  has  led  to  its  adoption  in  cases  in 
which  the  delivery  of  a  living  child  by  the  pelvic  route  is  so  open  to 
question  that  it  is  considered  proper  to  add  somewhat  to  the  maternal 
risk  for  the  sake  of  guaranteeing  the  birth  of  a  living  child;  but  the 
operation  is  not  a  proper  one  when  there  seems  to  be  a  serious  question 
that  the  preservation  of  the  fetal  life  will  be  attended  by  a  greatly  in- 
creased maternal  risk. 

There  is  furthermore  in  all  of  our  great  centers  of  population  a 
very  considerable  class  of  women  for  whom  childbearing  results  in 
serious  injury  to  health  and  sometimes  in  loss  of  life.  Examination  of 
these  patients  shows  that  there  is  no  pelvic  obstruction  and,  therefore, 
normal  delivery  is  possible,  but  the  results  of  pelvic  delivery  are  such 
that  the  patient  never  entirely  recovers  from  its  efifects  and  always  re- 
mains more  or  less  seriously  invalided.  Experience  has  shown  that  in 
many  of  these  subnormal  women  delivery  by  cesarean  section  is  a  health 
saving,  if  not  a  life  saving  procedure,  and  although  the  results  of  major 


"i6  CESAREAN  SECTION 

surgery  in  women  of  this  type  will  never  be  as  good  as  is  to  be  expected 
among  women  in  good  condition,  none  the  less  the  health  of  many 
women  will  be  preserved,  leaving  them  useful  citizens  in  the  community,' 
at  the  expense  of  a  relatively  slight  increase  in  the  immediate  mortality 
of  childbirth. 

These  three  indications,  the  preservation  of  maternal  life  and  health 
and  of  fetal  life,  constitute  the  only  justifiable  indications  for  the  opera- 
tion, but  many  operators  perform  cesarean  section  at  the  present  time 
when  by  no  possibility  can  either  mother  or  child  derive  any  benefit  from 
the  operation,  the  true  indication  being  the  inability  of  the  attendant  to 
select  the  proper  method  of  treatment  for  the  given  patient,  or  his 
ignorance  of  the  fact  that  cesarean  section  is  not  a  panacea  for  all 
obstetric  ills. 

The  great  majority  of  cesarean  sections  are  indicated  when  some 
disproportion  exists  between  the  size  of  the  fetal  head  and  the  maternal 
pelvis,  which  either  renders  the  birth  of  a  living  child  impossible  or  so 
dangerous  that  abdominal  delivery  is  the  safer  method  for  one  or  both 
patients.  Statistics  show  that,  of  women  with  contracted  pelves,  eight 
out  of  ten  can  be  delivered  successfully,  if  allowed  to  go  into  labor  and 
then  delivered  by  a  pelvic  operation,  and  the  figures  on  which  this  state- 
ment is  based  include  the  impossible  as  well  as  the  doubtful  pelves.  It  is, 
however,  impossible  to  predict  from  the  size  of  the  pelvis  alone  whether 
labor  will  be  possible  or  not,  for  of  two  women  with  Identical  pelvic 
measurements,  one  may  have  a  spontaneous  delivery,  whereas  the  other 
may  need  a  radical  operation  for  delivery,  even  though  the  children  may 
be  of  approximately  the  same  size.  Although  the  study  of  the  pelvis 
does  not  give  the  absolute  certainty  to  be  wished  for  in  regard  to  the 
outcome  of  labor,  none  the  less  the  information  to  be  obtained  from 
pelvic  mensuration  is  of  sufficient  value  to  warrant  its  performance  on 
every  patient,  combined  with  a  careful  comparison  of  the  child  with  the 
pelvic  canal,  the  latter  being  of  the  utmost  importance,  since  it  must  be 
remembered  that  disproportion  between  child  and  pelvis  is  more  im- 
portant than  the  size  of  either  alone,  and  that  pelvic  measurements  are 
of  little  value  except  in  extreme  cases,  unless  taken  into  consideration 
with  the  other  factors  involved  in  delivery. 

Since,  in  the  discussion  of  any  problem,  it  is  necessary  to  have  a 
starting  point,  even  though  conclusions  based  on  a  single  factor  may 
have  to  be  modified,  it  is  customary  to  initiate  the  study  of  the  indica- 
tions for  cesarean  section  by  a  consideration  of  the  pelvis,  for  the  reason 
that  in  most  cases  the  size  of  the  pelvic  canal  has  a  distinct  bearing  on 
the  wisdom  of  allowing  a  patient  to  attempt  labor. 


INDICATIONS  FOR  CESAREAN  SECTION  17 

Pelvic  Contraction. — The  most  common  indication  for  cesarean 
section  is  afforded  by  the  existence  of  disproportion  between  the  fetal 
head  and  the  maternal  pelvis  to  such  a  degree  as  to  offer  a  serious  me- 
chanical obstacle  to  delivery.  In  the  great  majority  of  cases  contraction 
or  deformity  of  the  pelvis  is  the  principal  factor  in  rendering  labor 
unduly  difficult,  but  it  must  be  remembered  that  it  is  no  more  difficult 
for  an  undersized  child  to  pass  through  a  contracted  pelvis  than  for 
an  over  large  child  to  pass  through  a  normal  pelvis.  Pelvic  contraction, 
therefore,  is  not  the  only  factor  to  be  considered  in  estimating  the 
probable  course  of  labor,  and  the  relation  of  the  given  child  to  the  given 
pelvis  must  also  enter  into  the  calculation.    The  methods  of  determining 


Fig.  I. — Pelvimeter. 

the  relation  of  the  child's  head  to  the  pelvic  canal  will  be  discussed 
later. 

The  pelvic  indication  for  cesarean  section  may  be  either  absolute  or 
relative. 

( I )  Absolute  Indication. — It  is  universally  agreed  that  whenever 
the  true  conjugate  diameter  measures  5  centimeters  (two  inches)  or 
less,  cesarean  section  is  absolutely  indicated  to  accomplish  delivery,  no 
matter  what  the  condition  of  the  patient  may  be,  without  regard  to 
the  length  of  time  she  may  have  been  in  labor  or  the  possible  presence 
of  uterine  infection.  This  is  due  to  the  fact  that  in  such  an  extreme 
degree  of  pelvic  contraction  the  delivery  of  a  normally  developed  or 
even  of  a  rather  small  child  is  practically  impossible,  even  after  embry- 
otomy, and  an  abdominal  delivery,  therefore,  offers  the  only  chance 
of  saving  either  the  maternal  or  fetal  life  and  is  called  for  in  all  cases. 
This  is  practically  the  same  indication  that  obtained  in  the  early  days 
of  the  operation,  when  the  maternal  mortality  resulting  from  cesarean 


t8 


CESAREAN  SECTION 


section  was  so  high  that  the  prognosis  of  the  operation  was  nearly- 
hopeless. 

(2)  Relative  Indication. — In  a  pelvis  with  a  true  conjugate 
diameter  measuring  between  5  and  jYi  centimeters  (two  to  three  inches) 
the  delivery  of  a  living,  average  sized  child  is  practically  impossible,  but 
it  is  usually  possible  to  deliver  a  child  on  whom  craniotomy  has  been 
performed,  without  undue  risk  to  the  mother,  unless  the  child  is  over 


Fig.  2.- 


-Measuring  Distance  Between  Anterior  Superior 
Spines. 


large.  Therefore,  in  patients  in  whom  a  pelvic  contraction  within  these 
limits  is  recognized,  as  it  should  be  when  it  exists,  during  pregnancy  or 
early  in  labor,  cesarean  section  at  term  is  the  elective  method  of  delivery 
in  all  cases  in  which  the  child  is  alive  and  in  good  condition.  If,  how- 
ever, at  the  time  when  the  pelvic  contraction  is  recognized  the  patient 
has  been  in  labor  a  long  time  and  is  showing  signs  of  exhaustion,  or 
has  by  repeated  manipulations  been  seriously  exposed  to  infection,  the 
prognosis  of  the  conservative  cesarean  operation  is  sufficiently  doubtful 


INDICATIONS  FOR  CESAREAN  SECTION 


19 


to  indicate  either  an  extraperitoneal  operation  or  cesarean  section  fol- 
lowed by  supravaginal  amputation  of  the  uterus,  according  to  the  ur- 
gency of  the  symptoms  and  the  judgment  of  the  surgeon,  hysterectomy 
being  usually  the  preferable  operation  in  cases  of  frank  infection.  If  the 
child  is  dead,  or  in  anything  but  good  condition,  craniotomy  is  the  opera- 
tion of  election  in  cases  of  this  type,  since  abdominal  section  on  a  patient 
late  in  labor  and  possibly  infected  is  never  justifiable,  except  in  the  inter- 


FiG.  3. — Measuring  External  Conjugate  Diameter. 

ests  of  the  child,  when  any  other  method  of  delivery  is  possible,  and  crani- 
otomy should  not  be  refused  in  such  a  case  for  purely  esthetic  reasons  un- 
der conditions  which  render  it  the  safest  method  of  treatment  for  the 
mother.  In  other  words,  the  interests  of  the  child  may  occasionally  afford 
sufficient  indication  to  render  a  serious  risk  to  the  mother  justifiable,  but 
unless  it  seems  practically  certain  that  the  life  of  the  child  can  be  guaran- 
teed by  running  grave  risks  for  the  mother,  her  interests  alone  should  be 
considered,  unless,  with  a  full  understanding  of  the  danger  to  herself, 
she  insists  that  the  child  Ix:  given  every  chance. 


20 


CESAREAN  SECTION 


Extension  of  Indications. — The  excellent  results  of  cesarean  sec- 
tion at  the  time  of  election  under  modern  conditions,  and  the  fact  that 
delivery  of  an  average  sized,  full  term  child,  except  after  craniotomy,  is 
so  difficult  as  to  be  practically  as  dangerous  as  cesarean  section  in  a  pelvis 
with  a  true  conjugate  diameter  of  less  than  7.5  centimeters,  have  had 
a  potent  influence  in  modifying  obstetric  opinion  in  favor  of  more  liberal 
views  toward  pelvic  contraction  as  an  indication  for  cesarean  section, 
with  the  result  that  the  upper  limit  of  the  absolute  indication  has  been 
raised  to  7.5   centimeters  when  the   conditions  which  predispose  to  a 


\\.> 


re>^' 


Fig  4. — Measuring  Diagonal  Conjugate  Diameter. 

successful  result  are  fulfilled.  These  are :  ( i )  The  child  must  be  alive 
and  in  good  condition.  (2)  The  patient  must  be  in  good  condition  and 
her  chances  must  not  have  been  compromised  by  the  exhaustion  of  a 
long  labor,  by  repeated  vaginal  examinations,  or  by  previous  attempts  at 
pelvic  delivery.  In  addition  the  membranes  must  not  have  been  ruptured 
for  more  than  a  few  hours.  (3)  The  patient  must  be  under  proper  con- 
ditions to  warrant  the  performance  of  a  major  operation,  i.e.,  either  in  a 
properly  equipped  hospital  or  in  a  home  where  hospital  conditions  can 
be  reproduced.  She  must  be  able  also  to  command  the  services  of  a 
properly  equipped  surgeon,  and  efficient  after  care  must  be  provided 
for.     If  any  of  these  conditions  cannot  be  fulfilled,  a  pelvic  operation 


INDICATIONS  FOR  CESAREAN  SECTION  21 

offers  a  so  much  better  chance  for  the  mother  that  it  should  be  selected, 
even  though  it  may  involve  the  loss  of  the  child. 

In  cases  in  v^hich  the  degree  of  pelvic  contraction  is  less  marked,  in 
which  the  true  conjugate  diameter  measures  between  7.5  and  8.5  centi- 
meters in  flat,  and  7.5  and  9  centimeters  in  generally  contracted  pelves, 
the  operation  may  be  indicated  as  an  elective  procedure.  In  patients 
whose  pelves  offer  this  degree  of  contraction  a  satisfactory  labor  will 
often  result  in  the  delivery  of  a  living  child  by  means  of  a  not  too  diffi- 
cult pelvic  operation,  but  it  is  exceedingly  difficult  to  estimate  the  course 
of  labor  in  advance,  and  many  children  are  lost  and  mothers  seriously 
injured  as  the  result  of  attempting  a  pelvic  delivery  under  such  conditions. 


Fig.   s. — Measuring   Diagonal   Conjugate 
Diameter  on  the  Fingers. 

A  large  proportion  of  the  patients  in  this  class  will  either  deliver  them- 
selves spontaneously  or  come  to  an  operative,  pelvic  delivery  of  not  undue 
difficulty,  and  the  exercise  of  the  wisest  obstetric  judgment  is  called 
for  to  determine  which  case  can  be  safely  delivered  through  the  pelvis 
after  a  labor  of  not  undue  severity  for  the  given  patient,  and  which 
should  be  subjected  to  a  radical  operation  for  delivery.  In  this  connec- 
tion it  must  not  be  forgotten  that  the  mere  possibility  of  delivery  through 
the  pelvis  is  not  the  only  factor  to  be  considered,  and  that  the  effect  of  a 
severe  labor  on  the  after  life  of  the  given  patient,  with  the  chance  of 
more  or  less  serious  laceration,  must  be  taken  into  account.  Two  women 
with  practically  identical  pelvic  measurements  and  with  children  of  ap- 
proximately the  same  size  may  have  totally  different  results.  One  may 
have  a  comparatively  easy,  spontaneous  labor,  while  the  other  may  require 


22 


CESAREAN  SECTION 


a  major  operation  to  insure  the  safe  delivery  of  a  living  child  and  the 
preservation  of  her  own  life  or  health.  In  the  latter  class  of  patients 
cesarean  section  is  indicated,  partly  to  save  the  mother  from  the  almost 
inevitable  damage  attendant  on  a  difficult  version,  high  forceps,  or 
craniotomy,  and  partly  to  guarantee  the  life  of  the  child;  but  it  is  often 
impossible  to  predict  with  any  degree  of  accuracy  in  the  given  patient 
what  the  character  of  her  labor  will  be,  and  the  comparison  between 
the  child  and  pelvis,  though  of  prime  importance,  is  not  the  only  factor 
in  the  problem. 

A  thorough  examination  of  the  patient  during  the  last  weeks  of 
pregnancy,  preferably  undertaken  under  full  anesthesia,  is  obligatory  in 


Figs.  6  and  7.- 


-Variation  in  Diagonal  Conjugate  Diameter  in  Accordance  with 
Height  and  Inclination  of  Symphysis   Pubis. 


these  cases,  together  with  a  careful  consideration  of  all  the  factors  in 
the  individual  case.  The  pelvis  should  be  carefully  explored  with  the 
half  hand,  so  that  no  pelvic  deformity,  which  may  not  be  indicated  by 
the  ordinary  measurements,  can  be  overlooked. 

The  attempt  should  be  made  to  impress  the  head  into  the  pelvis  by 
Miiller's  method  at  the  same  time.  If  the  lowest  point  of  the  head  can 
be  brought  to  the  lower  margin  of  the  symphysis  pubis,  it  can  be  regarded 
as  practically  certain  that,  if  fne.  patient  has  a  labor  of  ordinary  power, 
the  head  will  be  molded  into  the  pelvis,  sufficiently  at  least  for  the  per- 
formance of  a  low  or  mid  forceps  delivery  of  not  more  than  average 
difficulty,  and  cesarean  section  need  not  be  considered  unless  other  indica- 
tions are  present.  If,  however,  the  head  cannot  be  fitted  into  the  pelvic 
brim,  and  especially  if  it  overrides  the  symphysis,  the  case  is  not  so 
easily  settled  and  other  factors  must  be  taken  into  consideration.     If 


INDICATIONS  FOR  CESAREAN  SECTION 


23 


the  degree  of  overriding  is  marked,  it  is  fair  to  assume  that  the  head 
can  only  be  molded  into  the  brim,  if  at  all,  after  a  long  and  difficult 
labor,  which  will  involve  considerable  danger  to  the  child,  and  cesarean 
section  at  the  time  of  election  is  the  operation  of  choice  for  the  sake  of 
the  child,  provided  proper  facilities  can  be  arranged  for.  This  method 
of  delivery  will  also  save  the  mother  from  a  severe  labor,  which  may  have 


Fig.  8. — Palpating  Pubic  Arch. 

serious  after  effects  on  her  general  health,  and  unless  her  nervous  and 
physical  equipment  is  such  that  no  unfortunate  consequences  need  be 
feared,  even  though  labor  may  prove  to  be  unusually  severe  and  prolonged, 
this  fact  should  receive  careful  consideration. 

In  cases  in  which  the  overriding  is  slight,  or  in  which  no  overriding 
is  present,  and  yet  the  head  cannot  be  fitted  into  the  pelvis,  other  factors 
should  be  taken  into  consideration  in  deciding  the  problem. 

If  the  patient  is  a  primipara,  of  an  age  close  to  the  end  of  the  child- 
Ijearing  period,  an  elective  cesarean  delivery  offers  an  almost  sure  method 


24 


CESAREAN  SECTION 


of  securing  a  living  child  at  a  minimum  of  risk  to  the  mother.  The  im- 
mediate risk  of  life  to  the  mother  is  slightly  greater  in  abdominal  than 
in  pelvic  delivery  in  this  type  of  case',  but  this  is  more  than  compensated 
for  by  the  increased  safety  to  the  child,  in  addition  to  the  avoidance 
of  serious  laceration,  with  its  consequent  possible  invalidism  and  probable 
secondary  operation. 

If  the  patient  is  a  multipara  who  has  had  previous  obstetric  disasters, 
cesarean  section  should  be  chosen  without  hesitation  in  these  border  line 
cases,  unless  the  present  child  is  manifestly  smaller  than  the  previous 
children  have  been,  or  the  previous  disasters  can  be  traced  to  poor  judg- 


FiG.  9. — Measuring  Transverse  Diameter  at  Outlet. 

ment  or  operative  technic  on  the  part  of  the  former  attendant,  and  even 
then  the  obstetrician  must  be  very  sure  of  his  superior  ability  as  an 
operator  before  he  decides  to  run  the  risk  of  losing  another  child  for 
such  a  patient.  Many  children  have  been  unwarrantably  sacrificed,  be- 
cause the  physician  in  charge  of  the  second  labor  has  assumed  that  his 
superior  training  warranted  the  assumption  that  he  could  succeed  where 
his  predecessor  had  failed,  and  he  has  thus  been  led  into  the  error  of 
not  profiting  by  his  patient's  previous  history  and  has  sacrificed  her 
interests  to  his  own  conceit.  It  is  fair  to  say  that,  if  a  patient  with  a 
border  line  pelvis  has  lost  one  child  as  a  result  of  a  difificult  operative 
delivery,  cesarean  section  in  succeeding  pregnancies  is  advisable,  and 
that,  if  she  has  lost  more  than  one,  the  indication  is  absolute. 


INDICATIONS  FOR  CESAREAN  SECTION 


25 


The  examination  should  also  include  a  careful  estimation  of  the 
size  of  the  child's  head  and  comparison  of  it  with  the  maternal  pelvis  by 
the  various  methods  advised  for  measuring  the  fetal  head,  but  these 
procedures,  although  of  distinct  value,  do  not  give  accurate  information 
as  to  the  outcome  of  labor,  owing  to  the  fact  that  other  factors  enter 
into  the  problem  to  a  greater  or  less  extent.    It  is  undoubtedly  the  case 


Fig.  10. — Measurement  of  Anteroposterior  Diameter  at  Outlet 
(Williams'  Method). 

that  in  expert  hands  such  an  examination  will  reduce  the  margin  of  error 
to  a  minimum,  but  the  fact  remains  that  the  ultimate  result  in  a  certain 
number  of  cases  depends  on  other  factors  which  cannot  be  determined 
until  the  patient  has  been  in  labor  for  some  time.  The  other  factors 
which  must  be  taken  into  consideration  are :  the  probable  character  of 
the  labor,  i.e.,  the  strength  and  frequency  of  the  uterine  contractions, 
the  time  at  which  the  membranes  rupture,  whether  before  or  after  dilata- 
tion of  the  cervix  has  been  attained;  the  rigidity  of  the  soft  parts,  and 
the  molding  power  of  the  child's  head.    In  addition,  the  effect  of  a  hard 


26  CESAREAN  SECTION 

labor  on  the  individual  patient  must  be  taken  into  consideration  in  de- 
termining the  best  method  of  delivery,  since  in  women  who  are  below 
the  normal  standard,  either  physically  or  nervously,  the  exhaustion  of  a 
prolonged  and  severe  labor  may  leave  permanent  after  effects  of  a  more 
or  less  serious  character,  and  furthermore,  the  results  of  severe  lacera- 
tion may  have  a  very  detrimental  influence  on  a  patient's  after  health. 

( 1 )  Probable  Character  of  the  Labor. — In  a  primipara  the  character 
of  the  labor  cannot  be  surely  predicted.  As  a  rule  strong,  well  developed 
women  will  have  good  labors,  while  frail,  anemic  women  are  more  likely 
to  have  unsatisfactory  labors.  This  rule,  however,  is  by  no  means 
absolute,  and  flabby,  anemic  women  may  have  satisfactory  labors,  the 
uterus  developing  unlooked  for  power  and  the  resistance  of  the  soft  parts 
being  reduced  to  a  minimum,  while  in  some  strong,  healthy  women  the 
uterine  action  proves  feeble  and  unsatisfactory  from  the  start. 

The  nature  of  the  pelvic  contraction  may,  in  some  cases,  give  a  clue 
to  the  probable  character  of  the  labor.  In  patients  with  rachitic  pelves 
labor  is  apt  to  be  powerful  and  satisfactory  in  character  and  the  same 
holds  true  in  women  with  flat  pelves,  the  pelvic  contraction  being  a  purely 
local  condition  without  associated  change  in  the  uterine  musculature, 
the  latter  being  normal  and  capable  of  developing  the  necessary  power. 

In  women  with  generally  contracted  pelves,  due  to  a  lack  of  proper 
development,  the  pelvic  organs  are  also  apt  to  be  underdeveloped,  and 
labor  will  often  prove  ineffective,  owing  to  a  lack  of  proper  muscular 
development  of  the  uterus,  with  the  result  that  even  a  slight  pelvic  dis- 
proportion may  afford  too  great  an  obstacle  to  be  overcome  by  the  feeble 
uterine  forces. 

In  other  cases,  with  an  apparently  normal  pelvis,  the  uterine  develop- 
ment may  be  deficient,  as  is  evidenced  by  a  history  of  irregular  and  pain- 
ful menstruation,  suggesting  an  infantile  condition  of  the  uterus.  These 
symptoms  are,  however,  only  suggestive  and  do  not  afford  definite  evi- 
dence of  muscular  inefficiency  of  the  uterus;  but  they  deserve  some  con- 
sideration when  the  adaptation  between  the  head  and  pelvis  is  abnormal, 
and  in  doubtful  cases  may  very  properly  be  the  deciding  factor  in  the 
selection  of  the  method  of  delivery  most  appropriate  to  the  given  patient's 
needs,  and  result  in  the  choice  of  cesarean  section  at  the  time  of  election 
as  the  wisest  method  of  delivery  in  the  given  case,  although  in  doubtful 
cases  a  few  hours'  trial  of  labor  may  be  given  in  order  to  decide  the 
question. 

(2)  Dilatability  of  the  Cervix. — The  dilatation  of  the  cervix  to  the 
point  at  which  it  no  longer  offers  an  obstacle  to  the  birth  of  the  child 
is  a  sine  qua  non  of  successful  pelvic  delivery.     Under  normal  circum- 


INDICATIONS  FOR  CESAREAN  SECTION  27 

stances  this  is  accomplished  by  the  hydrostatic  action  of  the  "bag  of 
waters"  and  in  cases  of  the  early  rupture  of  the  membranes  by  the  pre- 
senting part.  As  a  general  rule  dilatation  is  materially  delayed  by  the 
premature  rupture  of  the  membranes,  even  when  the  head  is  well  in  the 
pelvis,  although  in  these  cases  the  delay  is  usually  relatively  unim- 
portant. 

When  disproportion  exists,  however,  between  the  fetal  head  and  the 
maternal  pelvis,  early  rupture  of  the  membranes  assumes  a  much  greater 
significance.  The  natural  dilator  of  the  cervix  is  lost,  and  the  presenting 
part  cannot  act  as  a  dilator  until  after  the  formation  of  a  considerable 
caput  succedaneum,  owing  to  the  fact  that  it  cannot  come  into  contact 
with  the  cervix  until  it  is  molded  into  the  pelvis,  which  as  a  rule  does 
not  occur,  at  least  completely,  until  dilatation  of  the  cervix  is  accom- 
plished. Since  the  molding  of  the  head  is  usually  accomplished  during 
the  second  stage  of  labor,  the  head  is  not  in  the  pelvis  and  thus  in  con- 
tact with  the  cervix  in  cases  of  even  moderate  disproportion,  and  progress 
ceases  until  the  edematous  caput  is  formed  to  act  as  a  dilator.  This 
loss  of  time  frequently  results  in  such  a  degree  of  exhaustion  of  the 
mother  as  to  call  for  prompt  operative  interference  before  dilatation  of 
the  cervix  is  accomplished,  or  the  lower  uterine  segment  may  become 
dangerously  overdistended,  with  consequent  danger  of  rupture  before 
proper  dilatation  of  the  cervix  is  accomplished.  Early  rupture  of  the 
membranes  should,  therefore,  be  considered  as  a  very  definite  indication 
in  favor  of  cesarean  section  in  cases  where  the  method  of  delivery  is 
doubtful,  as  in  cases  in  the  border  line  class,  and  even  in  cases  in  which 
little  doubt  is  felt  as  to  the  probability  of  pelvic  delivery,  if  labor  is 
satisfactory;  since  the  progress  of  labor  is  apt  to  be  so  seriously  inter- 
fered with  that  the  cervix  may  fail  of  satisfactory  dilatation  before 
exhaustion  of  either  the  patient  or  the  uterus  develops,  and  the  dangers 
of  an  operative  pelvic  delivery  greatly  increased. 

Careful  observation  of  the  progress  of  the  case  by  rectal  examination 
will  furnish  the  best  evidence  as  to  what  the  treatment  should  be,  and 
if  progress  is  not  steady  and  satisfactory  in  these  cases  prompt  abdominal 
delivery  Is  called  for.  Repeated  vaginal  examinations  to  determine 
progress,  though  somewhat  more  satisfactory  in  some  cases  than  rectal 
examination,  add  to  the  danger  of  infection  to  such  an  extent  that  in 
cases  in  which  abdominal  delivery  is  a  possibility  vaginal  examination 
should  be  dispensed  with  whenever  possible. 

Unsatisfactory  dilatation  of  the  cervix  and  persistently  inefiicient, 
irregular  uterine  contractions  should  be  considered  as  an  indication  for 
cesarean  section,  even  in  cases  with  unruptured  membranes,  when  any 


"28  CESAREAN  SECTION 

serious  doubt  exists  as  to  the  ability  of  the  head  to  pass  through  the 
pelvic  cavity  unless  markedly  molded.  Under  these  circumstances  it  is 
extremely  doubtful  if  labor  will  prove  satisfactory  at  any  time,  and  a 
delay  of  any  considerable  length  means  either  a  difficult  pelvic  operation 
with  considerable  danger  to  both  patients,  or  a  late  cesarean  section  with 
a  definite  increase  in  the  risk  to  the  mother.  There  is  no  advantage  to  be 
gained  by  a  long  delay  in  a  case  of  this  nature,  since  four  or  five  hours 
of  labor  will  furnish  an  almost  certain  clue  to  the  ultimate  character  of 
labor,  and  if  the  uterus  fails  to  function  properly  within  a  reasonable 
time,  it  is  almost  sure  that  labor  will  not  prove  efficient  in  overcoming 
a  serious  mechanical  obstacle.  Cesarean  section  is,  therefore,  indicated 
as  soon  as  the  inefficiency  of  the  labor  is  demonstrated. 

In  these  border  line  cases  the  outcome  is  to  a  certain  extent  doubtful, 
even  if  labor  is  satisfactory  in  character  in  the  beginning,  and  any  de- 
parture from  the  normal  should  be  met  by  a  prompt  change  in  policy, 
unless  the  delay  already  permitted  is  felt  to  have  seriously  increased  the 
risk  of  abdominal  delivery,  or  unless  vaginal  examination  has  been  freely 
practised  in  the  attempt  to  study  progress. 

(3)  The  Molding  Power  of  the  Fetal  Head. — The  question  as  to 
whether  a  given  fetal  head  can  pass  through  a  given  pelvis  can  in  some 
cases  only  be  answered  by  a  knowledge  of  the  degree  of  molding  which 
a  given  head  will  undergo  when  subjected  to  the  forces  of  labor.  Un- 
fortunately we  cannot  predict  for  the  given  case,  if  the  patient  is  a 
primipara,  but  must  wait  for  sufficient  dilatation  of  the  cervix  to  permit 
of  palpation  of  the  head  before  arriving  at  a  decision.  In  a  multipara 
some  information  may  be  gained  from  the  history  of  previous  labors. 
If  the  previous  children  have  had  large  heads  with  small  fontanelles  and 
narrow  sutures  it  is  probable  that  this  child  will  have  a  similar  head 
and  the  molding  process  be  slow  and  difficult,  even  if  it  be  possible;  and 
unless  the  first  stage  of  labor  is  promptly  completed,  so  that  the  whole 
power  of  the  unexhausted  uterus  can  be  exerted  to  accomplish  molding 
of  the  head,  the  waiting  policy  should  be  abandoned  and  cesarean  section 
performed. 

The  question  can  only  be  definitely  answered  by  palpation  of  the  fetal 
head  through  the  partly  dilated  cervix,  which  means  a  delay  of  several 
hours  at  the  best.  If  on  examination  through  the  partly  dilated  os  it 
appears  that  the  head  is  poorly  ossified  and  the  sutures  and  fontanelles 
are  widely  open,  and  the  bones  of  the  skull  are  parchment  like  to  the 
touch,  a  marked  degree  of  molding  is  possible  and  delivery  may  be  ac- 
complished from  below  by  a  not  too  difficult  operation,  after  it  has  taken 
place,  if  the  uterine  contractions  are  of  average  strength.    On  the  other 


INDICATIONS  FOR  CESAREAN  SECTION  29 

hand,  if  the  sutures  and  fontanelles  are  nearly  closed  and  the  bones  are 
firm  and  hard,  molding  is  sure  to  be  a  long  and  difficult  process  and  the 
powers  of  the  patient  may  fail  before  it  is  accomplished  to  a  satisfactory 
degree,  even  though  the  uterine  contractions  may  be  of  unusual  strength. 
In  these  cases  the  proper  treatment  must  depend  on  the  estimation  of 
the  patient's  ability  to  undergo  a  severe  labor  without  serious  after  effects 
and  on  the  estimated  degree  of  the  force  exerted  by  the  uterus.  If  any 
real  doubt  exists  in  a  case  of  this  nature,  cesarean  section  is  the  opera- 
tion of  choice,  and  the  operation  should  be  undertaken  as  soon  as  any 
real  doubt  as  to  the  probable  outcome  arises,  since  if  interference  is 
delayed  until  failure  is  absolutely  demonstrated,  the  prognosis  of  the 
operation  will  be  seriously  changed  for  the  worse  for  both  mother  and 
child. 

In  the  majority  of  border  line  cases  a  few  hours'  trial  of  labor  will 
give  a  strong  hint  as  to  the  probable  outcome,  and  if  labor  is  conducted 
aseptically  and  the  progress  of  the  case  followed  by  abdominal  palpation 
and  rectal  examination,  the  risk  to  the  mother  will  be  only  slightly  in- 
creased over  that  of  operation  at  the  time  of  election,  i.e.,  before  labor 
begins,  or  in  the  early  hours  of  labor.  In  fact  a  certain  advantage  may 
be  gained  by  the  fact  that  a  moderate  amount  of  cervical  dilatation  will 
occur,  which  theoretically  will  provide  for  more  satisfactory  drainage 
later  and  may  obviate  the  necessity  for  dilatation  of  the  cervix  during 
the  convalescence  in  case  a  tendency  to  retention  of  lochia  occurs,  although 
m  my  experience  this  is  a  theoretical  advantage  only. 

Of  course  the  result  of  labor  cannot  be  accurately  predicted  in  a 
certain  proportion  of  cases  until  the  patient  has  had  a  true  test  of  labor, 
i.e.,  two  hours  or  more  in  the  second  stage,  but  a  few  hours  of  labor 
will  determine  whether  the  case  is  likely  to  progress  to  a  favorable  con- 
clusion, except  in  so  far  as  the  ultimate  molding  of  the  head  is  con- 
cerned. 

If  the  progress  of  labor  is  anything  but  perfectly  satisfactory,  cesarean 
section  at  once  becomes  the  indicated  procedure,  provided  the  patient 
has  not  been  compromised  by  repeated  vaginal  examinations. 

If  the  progress  is  satisfactory  and  the  cervix  is  dilating  properly,  so 
that  it  is  evident  that  the  head  will  be  subjected  to  the  molding  power 
of  the  uterus  before  the  patient  is  exhausted,  labor  should  be  permitted 
to  proceed  on  the  understanding  that  cesarean  section  will  be  considered 
as  contraindicated  after  a  thorough  test  of  labor,  except  in  the  rare 
case  when,  the  test  of  labor  having  failed  to  mold  the  head  into  the  pelvis, 
some  unusual  factor  calls  for  the  delivery  of  a  living  child,  even  at  con- 
siderable risk  to  the  mother.     Such  a  condition  should  be  recognized, 


30  CESAREAN  SECTION 

however,  before  labor  begins  and  should  call  for  a  primary  cesarean 
section,  since  whenever  the  life  of  the  child  assumes  an  unduly  great 
importance,  the  risks  involved  in  applying  a  test  of  labor  should  not  be 
taken  whenever  any  reasonable  doubt  exists  as  to  the  probable  outcome, 
inasmuch  as  an  elective  operation  will  give  better  results  for  both  mother 
and  child  than  a  late  section  or  a  difficult  pelvic  delivery. 

(4)  Effect  of  Labor  on  the  Patient. — In  considering  the  best  method 
of  dehvery  for  patients  with  a  moderate  pelvic  contraction,  the  effect  of 
a  long,  hard  labor  on  the  patient  should  be  carefully  considered.  There 
exist  in  every  large  city  many  women  who  are  physically  or  nervously 
poorly  equipped  and  who  will  suffer  more  or  less  seriously  if  they  are 
subjected  to  a  serious  strain,  and  may  possibly  never  fully  recover.  The 
frail,  anemic  woman,  who  has  normally  just  enough  strength  for  the 
ordinary  burdens  of  life,  is  usually  a  poor  risk  to  be  subjected  to  a 
severe  physical  strain  and  may  suffer  seriously,  if  not  permanently,  from 
the  effects  of  a  hard  labor.  One  not  infrequently  sees  patients  who  have 
not  recovered  from  the  strain  of  a  normal  labor  for  many  months,  even 
though  the  strain  was  not  an  unduly  severe  one.  To  subject  such  a 
patient  to  a  labor  which  would  tax  the  powers  of  the  strongest  woman 
may  mean  a  long  period  of  invalidism,  which  could  be  avoided  very 
properly  by  an  abdominal  delivery,  since  it  is  a  fact  that  many  frail 
women  stand  an  operation  well  and  show  very  slight  after  effects,  but 
recuperate  very  slowly  and  imperfectly  from  a  severe  exhaustion,  such 
as  is  necessitated  by  a  labor  of  no  more  than  average  severity. 

An  unstable  nervous  equilibrium  may  also  furnish  a  perfectly  good 
indication  in  these  cases.  Many  women  expend  their  whole  nervous 
energy  in  the  routine  of  their  daily  lives  and  are  unfitted  to  bear  any 
additional  strain.  Such  women  not  infrequently  suffer  so  severely  from 
the  nervous  exhaustion  incident  to  a  normal  labor  as  to  be  invalided 
more  or  less  seriously  for  a  considerable  time,  and  may  never  entirely 
recover  from  the  effects  of  childbirth,  even  though  no  physical  lesion 
can  be  determined;  and  many  cases  of  more  or  less  severe  nervous  break- 
down follow  labor  in  patients  who  have  no  reserve  of  nerve  force  and 
who  are  living  up  to  their  limits  in  their  daily  lives. 

If  a  patient's  previous  history  indicates  that  her  nervous  stamina  is 
below  par  and  that  any  added  burden  in  her  ordinary  life  has  been  fol- 
lowed by  a  nervous  breakdown,  cesarean  section  should  be  carefully 
considered  as  a  conservative  procedure,  even  in  patients  with  normal 
pelves,  unless  careful  examination  shows  that  owing  to  the  relaxed  con- 
dition of  the  soft  parts  the  labor  is  sure  to  be  an  easy  one.  If  a  patient 
of  this  sort  has  any  pelvic  contraction,  even  of  moderate  degree,  the 


INDICATIONS  FOR  CESAREAN  SECTION  31 

method  of  delivery  which  adds  least  to  the  burdens  the  patient  is 
staggering  under  should  be  chosen,  in  order  to  diminish  the  strain  as  far 
as  possible.  The  easiest  method  for  such  a  patient  is  undoubtedly 
cesarean  section,  and  my  experience  has  shown  that  the  results  of  the 
operation  in  patients  of  this  class  are  much  better  than  those  seen  after 
a  hard  labor,  and  that  a  very  slight  increase  in  risk  is  involved. 

The  pain  of  labor  per  se,  without  taking  into  consideration  the  severe 
muscular  exertion,  seems  to  be  too  much  of  a  burden  for  many  women 
of  this  class,  and  not  infrequently  creates  a  permanent  impression  on 
the  patient,  so  that  the  rest  of  her  life  is  spent  in  fear  of  a  repetition  of 
the  horrors  she  remembers,  a  condition  which  might  have  been  avoided 
if  her  needs  had  been  recognized  and  the  strain  of  labor  avoided. 

Another  type  of  patients  in  whom  the  exhaustion  of  a  severe  labor 
may  develop  permanent  after  effects  is  the  class  who  do  not  improve  in 
general  condition  during  pregnancy  and  who  come  to  labor  in  a  poorer 
general  condition  than  existed  before  the  beginning  of  pregnancy.  The 
average  woman  improves  markedly  in  general  health  during  pregnancy, 
and  the  patient  who  does  not  so  improve  should  cause  her  attendant 
serious  anxiety  as  labor  approaches.  Examination  may  show  nothing  to 
account  for  the  lowered  vitality,  but  the  condition  is  not  a  normal 
one.  I  believe  that  many  of  these  patients  are  suffering  from  a  low 
grade  toxemia  as  a  result  of  which  they  become  unfitted  to  bear  the 
strain  of  a  severe  labor,  and  if  the  degree  of  pelvic  contraction  is  any- 
thing but  slight,  cesarean  section  offers  the  best  method  of  delivery. 

Cardiac  Conditions. — Patients  who  show  definite  heart  lesions  are 
seldom,  if  ever,  good  risks  for  any  but  the  easiest  of  labors,  even  though 
no  pelvic  abnormality  exists,  particularly  patients  with  mitral  stenosis  or 
aortic  regurgitation,  and  the  indication  is  emphasized  if  there  have  been 
attacks  of  decompensation  during  or  before  pregnancy.  Cesarean  sec- 
tion is  always  indicated  in  cardiac  cases  when  any  reason  exists  to  expect 
a  difficult  labor.  This  is  particularly  true  on  account  of  the  danger  of 
cardiac  failure  occurring  during  or  shortly  after  a  labor  of  not  more 
than  average  severity.  The  lives  of  many  women  have  been  sacrificed, 
and  many  others  have  been  left  as  cardiac  invalids,  owing  to  the  mistaken 
idea  that  a  heart  already  damaged  can  be  with  safety  allowed  to  undergo 
the  severe  strain  of  a  labor  which  may  test  the  reserve  of  even  a  normal 
heart  to  the  utmost. 

Another  group  of  patients  who  should  not  be  subjected  to  any  but 
the  easiest  of  labors  comprises  those  who,  though  the  heart  shows  no 
definite  lesion  on  examination,  yet  develop  dyspnea  and  tachycardia  on 
the  slightest  exertion  during  pregnancy.    With  them  should  be  included 


32  CESAREAN  SECTION 

the  patients  who  are  suffering  from  a  presumable  myocarditis  following 
acute  infection,  patients  who  after  a  reasonable  interval  of  normal  health 
would  probably  make  a  complete  recovery,  but  whose  convalescence  is 
retarded  by  the  burden  which  pregnancy  throws  on  the  weakened  heart 
muscle  and  who  show  minor  cardiac  symptoms  throughout  pregnancy. 
Such  patients  are  poor  risks  to  be  subjected  to  any  avoidable  strain, 
since  the  heart  muscle  is  flabby  and  the  strain  of  even  an  easy  labor 
may  result  in  acute  cardiac  dilatation,  which  may  prove  alarming  and 
possibly  fatal.  Furthermore  the  strain  thrown  on  the  heart  by  labor 
may  retard,  if  not  prevent,  complete  restoration  of  the  heart  to  a  normal 
condition.  In  multiparae  with  relaxed  soft  parts  a  short  first  stage  will 
do  little  if  any  harm,  but  the  second  stage  of  labor  should  be  curtailed 
by  operative  means.  In  primiparae  with  such  a  cardiac  condition  labor 
should  be  avoided  and  the  patient  delivered  by  cesarean  section,  even 
though  the  pelvis  is  normal  and  there  is  no  reason  to  expect  any  greater 
strain  on  the  heart  than  is  inevitable  in  a  normal  labor.  If  any  dispro- 
portion exists  between  the  child  and  the  pelvis,  as  in  border  line  cases, 
the  indication  for  cesarean  section  becomes  an  absolute  one,  since  the 
strain  of  a  labor  which  will  probably  be  of  more  than  average  severity 
is  sure  to  produce  harmful  effects  on  such  a  heart  muscle,  and  may 
result  in  chronic  invalidism,  if  not  in  death  during  labor.  Acute  dilata- 
tion of  the  heart  with  its  attendant  dangers  will  develop  in  a  certain 
proportion  of  these  cases,  if  they  are  subjected  to  labor,  and  in  others  the 
return  of  the  heart  to  a  normal  condition  will  be  retarded,  while  in 
some  permanent  damage  will  result  from  the  strain,  and  the  heart  will 
never  become  perfectly  normal.  Cesarean  section  is,  of  course,  not 
without  some  risk  in  these  patients,  but  the  risk  will  be  only  slightly 
greater  than  in  normal  women,  unless  the  heart  is  showing  signs  of  de- 
compensation at  the  time  of  operation.  Even  then  both  the  immediate 
and  ultimate  results  will  be  better  than  if  the  patient  is  allowed  to 
undergo  the  strain  of  labor,  or  is  subjected  to  a  difficult  operative  delivery 
per  vaginam.  In  these  cases  cesarean  section  is  the  operation  of  election, 
not  because  it  can  be  guaranteed  to  give  perfect  results,  but  because  labor 
followed  by  an  operative  delivery  is  exceedingly  dangerous  for  these 
patients  and  cesarean  section  is  the  lesser  evil. 

Pelves  with  a  True  Conjugate  of  More  than  Nine  Centimeters. 
— In  pelves  with  only  a  moderate  degree  of  contraction  of  the  true  con- 
jugate diameter  cesarean  section  will  comparatively  seldom  be  the. 
operation  of  election,  unless  the  child  is  over  developed  or  some  other 
indication  than  the  pelvic  one  exists. 

In  a  primipara  with  such  a  pelvis  the  attention  of  the  attendant 


INDICATIONS  FOR  CESAREAN  SECTION  33 

should  be  called  to  the  existence  of  the  contraction  by  the  fact  that  the 
fetal  head  does  not  descend  into  the  pelvic  canal  in  the  latter  part  of 
pregnancy,  rather  than  by  the  pelvic  measurements.  The  non-engage- 
ment of  the  fetal  head  per  se  should  call  for  a  thorough  pelvic  investiga- 
tion, preferably  under  anesthesia,  when  the  extent  of  the  pelvic  con- 
traction would  be  ascertained.  If  the  true  conjugate  is  more  than 
nine  centimeters  and  the  child  is  of  no  more  than  average  size,  radical 
operation  will  seldom  be  called  for,  although  the  course  of  labor  should 
be  carefully  observed  from  the  beginning  and  any  departures  from  the 
normal  should  be  promptly  investigated  and  receive  proper  treatment. 
If,  however,  labor  is  normal  from  the  beginning,  a  pelvic  delivery  is 
almost  certain  after  a  labor  of  little  more  than  average  severity. 

If,  however,  the  child  is  above  the  average  size,  cesarean  section 
will  often  prove  the  operation  of  election,  since  the  important  factor  is 
the  comparison  between  the  child  and  the  pelvis  and  not  the  size  of  either 
by  itself.  In  doubtful  cases  a  test  of  labor  (as  described  in  the  preceding 
section)  should  be  carried  out  under  full  aseptic  precautions  and  the 
ultimate  treatment  of  the  case  decided  by  this  test. 

In  multiparae  the  history  of  previous  lalx)rs,  plus  the  size  of  the 
present  child,  should  be  the  determining  factor  in  the  choice  of  treat- 
ment. Women  who  have  lost  a  child  in  a  previous  labor  should  be 
delivered  by  cesarean  section,  unless  the  present  child  is  manifestly, 
distinctly  smaller  than  the  previous  one,  whereas  women  who  have  been 
successfully  delivered  in  previous  labors,  unless  by  unduly  difficult  opera- 
tions or  at  the  expense  of  serious  injury  to  the  soft  parts,  should  be 
allowed  to  go  into  labor  without  fear,  unless  the  present  child  is  distinctly 
larger  than  the  previous  children,  in  which  case  cesarean  section  may 
very  properly  be  indicated. 

The  presence  of  any  complicating  factor,  such  as  cardiac  disease, 
subnormal  equipment,  etc.,  will  very  properly  call  for  a  change  of  policy 
in  regard  to  patients  with  a  slight  degree  of  pelvic  contraction,  and 
cesarean  section  may  be  indicated  on  account  of  the  complicating  con- 
dition, but  the  pelvis  per  se,  in  cases  in  this  class,  will  seldom  necessitate 
the  operation. 

Malpresentations,  or  malpositions,  of  the  child  should  have  some 
influence  in  determining  the  course  of  treatment  in  doubtful  cases.  It 
is  well  recognized  that  transverse  and  face  presentations  occurring  in 
primiparae  furnish  definite  evidence  of  disproportion  between  the  fetal 
head  and  the  pelvis.  The  discovery  of  such  an  abnormality  in  a  patient 
whose  pelvis  has  already  been  recognized  as  somewhat  contracted  may 
well  prove  a  sufficient  indication   for  cesarean  section,   since  in  these 


34 


CESAREAN  SECTION 


cases  a  more  or  less  difficult  operation  is  almost  surely  necessary  to  effect 
delivery,  and  the  danger  to  the  child  is  great,  inasmuch  as,  owing  to  the 
malposition,  the  head  will  probably  be  dragged  through  the  pelvis  in  an 
unmolded  condition,  which  will  add  greatly  to  the  danger  to  the  fetal 
life  and  the  maternal  tissues.  In  multiparae  the  occurrence  of  mal- 
positions is  less  significant,  since  the  soft  parts  of  the  mother  will  offer 
little  resistance  to  delivery,  and  the  only  problem  to  be  determined  is 
the  relation  of  the  fetal  head  to  the  pelvis. 

Contraction  o£  the  Pelvic  Outlet. — As  a  rule,  in  cofisidering  pelvic 
contraction  as  an  indication  for  cesarean  section,  attention  is  directed 
to  the  pelvic  brim  and  the  outlet  receives  little  or  no   consideration. 


Figs,    ii    and    12. — Importance   of   Anterior    and    Posterior    Sagittal   Diameters: 

Spontaneous  Delivery. 


V 


Williams  has  shown  that  contraction  of  the  outlet  of  the  pelvis  is 
probably  the  most  common  form  of  contraction  met  with  among  white 
women  in  this  country,  and  the  outlet  should  therefore  always  be  meas- 
ured as  a  routine  in  studying  the  pelvis.  It  is  commonly  stated  that  a 
transverse  diameter  of  7  centimeters  or  less  is  a  positive  indication  for 
an  abdominal  delivery.  Unfortunately  the  question  cannot  be  settled  as 
easily  as  this  and  further  study  of  this  type  of  pelvic  contraction  is 
necessary.  As  Klien  has  pointed  out,  the  length  of  the  transverse  diam- 
eter, neither  by  itself  nor  in  combination  with  the  anteroposterior  diam- 
eter of  the  outlet,  furnishes  sufficient  information  for  the  adoption  of  a 
settled  policy.  Serious  dystocia  may  result  in  cases  in  which  the  degree 
of  contraction  is  only  moderate,  and  spontaneous  delivery  may  sometimes 
occur  in  patients  who  present  extreme  degrees  of  contraction. 


INDICATIONS  FOR  CESAREAN  SECTION 


35 


This  apparent  discrepancy  is  readily  explained,  however.  It  is  evi- 
dent that  the  shortening  of  the  bisischial  diameter  is  associated  with  a 
narrowing  of  the  pubic  arch  and  an  approach  to  the  male  type  of  pelvis. 
As  the  arch  becomes  narrowed  a  smaller  segment  of  the  head  can  pass 
beneath  it,  and  in  the  most  marked  cases  the  only  portion  of  the  pelvic 
outlet  that  the  head  can  enter  is  posterior  to  the  bisischial  diameter.  In 
such  cases  it  is  evident  that  delivery  will  be  impossible  unless  the  posterior 
portion  of  the  outlet  is  sufficiently  enlarged  to  permit  the  passage  of 
the  head,  and  that  the  important  diameter  is  the  distance  between  a  line 
joining  the  ischial  tuberosities  and  the  tip  of  the  sacrum,  and  not  the 
anteroposterior  diameter  of  the  outlet  as  a  whole.  This  diameter  is 
known  as  the  posterior  sagittal  diameter  of  the  outlet  and  can  be 
readily  measured  by  the  use  of  one  of  the  specially  devised  pelvimeters. 


Figs.  13  and  14. — Importance  of  Anterior  and  Posterior  Sagittal  Diameters  : 

Cesarean  Section. 

For  spontaneous  delivery  to  occur,  it  is  evident  that  the  posterior 
sagittal  diameter  must  increase  in  length  in  proportion  to  the  shortening 
of  the  bisischial,  and  it  is  possible  to  calculate  with  fair  accuracy  the 
amount  of  increase  necessary  to  render  delivery  through  the  pelvis 
probable. 

Williams  gives  the  following  figures,  which  may  be  accepted  as 
being  as  accurate  as  pelvic  measurements  by  themselves  can  ever  be  in 
formulating  a  prognosis,  and  which  show  approximately  the  increase 
in  the  posterior  sagittal  diameter  necessary  to  permit  the  average  fetal 
head  to  pass  the  outlet  in  cases  of  marked  contraction  of  the  transverse 
diameter : 

Transverse    diameter  8      cm. ;    posterior    sagittal     7.5  cm. 

<(  «  _  a  «  n  o         " 

6.5    "  "  "  8.S    "    . 

"  6       "  "  "  9      " 

5-5    "  "  "         10      " 


36 


CESAREAN  SECTION 


At  the  best,  however,  the  pelvic  measurements  are  only  one  of  the 
factors  involved  in  the  question,  and  it  is  a  not  uncommon  occurrence 
for  patients  with  relatively  normal  measurements  to  develop  serious 
dystocia,  and  on  the  other  hand  for  patients  with  extremely  doubtful 
measurements  to  have  a  spontaneous  labor.  It  is  necessary  also  for 
other  factors  to  be  taken  into  consideration  before  deciding  on  the  treat- 
ment of  the  individual  patient. 

The  size  of  the  child  must  be  taken  into  account,  since  the  measure- 
ments given  are  considered  in  relation  to  a  child  of  average  size  and 
not  to  one  which  is  overdeveloped,  proper  molding  of  the  head  being 
often  as  necessary  for  successful  passage  of  the  outlet  as  it  is  for  entrance 
into  the  brim.    Over  large  children  are  apt  to  have  large  and  well  ossified 


Fig.   15. — Measurement  of  Anterior  and  Posterior  Sagittal  Diameters 
WITH  Thoms'  Pelvimeter. 

heads,  and  since,  in  cases  of  funnel  pelvis,  the  head  is  already  in  the 
cavity  of  the  pelvis  and  its  size  can  only  be  estimated  with  difficulty,  the 
size  of  the  child  as  a  whole  must  be  taken  as  a  guide  to  the  size  of 
the  head. 

The  depth  to  which  the  head  enters  the  pelvis  before  meeting  obstruc- 
tion furnishes  a  certain  amount  of  information.  If  the  head  remains 
above  the  ischial  spines  and  cannot  be  forced  lower,  even  under  anesthesia, 
the  ability  of  the  head  to  mold  through  the  outlet  is  at  least  open  to  ques- 
tion in  marked  cases  of  funnel  pelvis.  If,  however,  it  is  possible  to  push 
the  head  well  down  onto  the  pelvic  floor  before  labor  is  far  advanced, 
it  will  almost  certainly  come  through  the  outlet  without  great  difficulty, 
even  in  cases  of  fairly  marked  contraction. 

The  position  of  the  fetal  head  is  also  of  some  importance.  In  cases 
of  posterior  position  of  the  occiput  the  normal  rotation  to  the  arch  is 


INDICATIONS  FOR  CESAREAN  SECTION  37 

apt  to  be  interfered  with,  and  the  head  not  infrequently  becomes  impacted 
while  still  posterior,  to  such  a  degree  that  rotation  to  the  arch,  even  by 
means  of  the  Scanzoni  maneuver,  becomes  a  matter  of  considerable  diffi- 
culty, with  a  definite  increase  in  danger  to  the  child;  then  if  rotation 
fails  extraction  of  the  child  may  be  impossible  or  necessitate  the  use  of 
such  force  as  to  cause  its  death.  In  such  cases  a  resort  to  pubiotomy 
will  solve  the  problem  with  least  danger  to  mother  and  child,  unless 
infection  has  already  occurred,  but  if  the  operator  is  not  equipped 
to  perform  this  operation  the  only  alternatives  are  cesarean  section,  a 
brutal  forceps  extraction,  or  craniotomy. 

Owing  to  the  fact  that  the  anterior  portion  of  the  pelvic  outlet  is 
not  available  for  the  passage  of  the  head,  the  perineum  is  subjected  to 
much  greater  distention  than  in  normal  cases  and  serious  lacerations  may 
result.  It  is  evident  that  a  considerable  proportion  of  complete  perineal 
lacerations  are  inevitable  in  cases  of  marked  outlet  contraction,  on  ac- 
count of  the  backward  displacement  of  the  head,  if  a  pelvic  delivery  is 
undertaken.  This  fact  should  be  given  some  weight  in  patients  who 
bear  pain  and  discomfort  badly,  and  a  cesarean  section  may  very  properly 
be  considered  in  certain  cases  in  which  the  markedly  contracted  outlet 
renders  the  liability  to  serious  laceration  a  factor  in  the  case,  especially 
in  elderly  primiparae,  since  the  patient  may  well  be  better  off  after  a 
cesarean  section  than  after  a  complete  laceration  which  does  not  heal 
properly  and  requires  secondary  operation  for  its  relief. 

After  Operations  for  Pelvic  Repair. — Multiparae,  with  marked  con- 
traction of  the  outlet,  who  give  a  history  of  difficult  delivery  at  previous 
labors,  even  though  the  children  may  have  lived,  and  who  have  suffered 
from  serious  lacerations  which  have  been  successfully  repaired,  present 
a  definite  indication  for  cesarean  section.  This  is  the  case  because  a 
more  or  less  forcible  operation  will  be  necessary  to  effect  delivery,  and, 
owing  to  the  fact  that  the  cicatricial  tissue  left  after  the  operation  for 
repair  will  probably  not  stretch  sufficiently  to  permit  delivery,  a  severe, 
if  not  complete,  laceration  is  almost  inevitable.  This  laceration  being 
largely  through  scar  tissue,  the  vitality  of  which  is  low,  will  in  all 
probability  heal  only  partially  when  sutured  and  require  a  secondary 
operation  for  relief.  Furthermore,  the  increasing  size  of  children  in 
successive  pregnancies  tends  to  render  each  succeeding  delivery  more 
difficult,  and,  therefore,  more  dangerous  to  the  child  as  well  as  to  the 
maternal  tissues.  For  these  reasons  it  is  clear  that,  from  the  standpoint 
of  both  mother  and  child,  certain  very  definite  advantages  appertain  to 
cesarean  section  as  an  elective  procedure  in  such  cases,  even  though  a 
pelvic  delivery  may  be  possible,  and  the  avoidance  of  invalidism  and 


38  CESAREAN  SECTION 

secondary  operation  will  often  indicate  cesarean  section  as  the  operation 
of  election. 

Elderly  Primiparae  with  Funnel  Pelves. — In  elderly  primiparae 
who  show  contraction  of  the  pelvic  outlet  of  even  a  moderate  degree 
cesarean  section  is  distinctly  the  operation  of  election  for  twO'  reasons : 
in  the  first  place,  all  danger  to  the  child  should  be  avoided,  unless  it 
involves  too  great  an  increase  in  the  risk  to  the  mother,  since  it  is  very 
possible  that  there  may  never  be  another  pregnancy  in  women  of  forty 
or  over,  and  no  serious  risk  of  losing  the  child  during  pelvic  delivery  is 
justifiable  when  its  life  can  be  practically  guaranteed  by  abdominal  de- 
livery. Furthermore,  in  this  class  of  patient  the  soft  parts  are  more 
apt  to  be  rigid  than  in  younger  women  and,  therefore,  are  more  liable 
to  extensive  laceration  with  its  consequent  disability.  I  believe  that  the 
majority  of  primiparae  over  forty  years  of  age  are  best  delivered  by 
cesarean  section  at  the  time  of  election,  both  to  avoid  the  possible  loss 
of  the  child,  and  severe  laceration,  which  is  often  inevitable  if  pelvic 
delivery  is  attempted,  even  though  the  pelvis  may  be  normal;  and  if  the 
patient  shows  even  moderate  contraction  of  the  outlet  abdominal  delivery 
is,  in  my  opinion,  even  more  distinctly  indicated. 

Young  Primiparae  with  Funnel  Pelves. — In  young  primiparae  with 
funnel  pelves  the  question  is  an  open  one.  The  performance  of  cesarean 
section  on  young  women  is  liable  to  mean  repeated  operations,  until 
finally  the  patient  is  sterilized  to  avoid  their  necessity.  Some  authorities, 
therefore,  recommend  a  primary  pubiotomy  in  these  cases,  in  the  hope 
that  not  only  will  the  present  child  be  successfully  delivered,  but  that  as 
a  result  of  the  operation  the  pelvis  will  be  sufficiently  enlarged  to  permit 
of  the  occurrence  of  spontaneous  labor  in  subsecjuent  pregnancies.  My 
own  personal  preference  is  for  cesarean  section  in  this  type  of  patient, 
but  the  excellent  results  which  some  writers  report  after  primary  pubi- 
otomy must  be  taken  into  consideration  before  definitely  dismissing  the 
question  as  settled.  Other  writers  do  not  seem  to  have  been  fortunate  in 
securing  permanent  enlargement  of  the  pelvis  after  pubiotomy,  though 
the  operation  otherwise  proved  successful,  and  in  the  absence  of  a  definite 
agreement  as  to  the  results  to  be  expected  in  pubiotomy,  both  as  regards 
the  future  of  the  patient  from  a  childbearing  standpoint,  as  well  as  the 
immediate  risk  to  life,  the  wiser  course  is  cesarean  section  in  doubtful 
cases.  By  this  means  the  life  of  the  child  can  be  practically  guaranteed, 
and  the  mother  will  be  restored  promptly  to  perfect  health.  The  danger 
to  the  maternal  life  in  cesarean  section  in  good  hands,  in  a  proper  hos- 
pital, and  when  performed  on  a  patient  in  good  general  condition,  should 
not  be  any  greater  than,  if  as  great  as,  that  attending  pubiotomy,  if  one 


INDICATIONS  FOR  CESAREAN  SECTION  39 

can  judge  by  the  general  statistics,  although  such  a  series  of  cases  as 
published  by  Williams  would  lead  one  to  suppose  that  pubiotomy  is  not 
attended  by  risk  to  life.  Other  operators,  however,  have  not  had  as 
good  results,  and  there  would  seem  to  be  a  definite,  though  small,  mor- 
tality attendant  on  pubiotomy,  practically  as  great  as  that  attending  the 
primary  cesarean  section.  Furthermore,  pubiotomy  undoubtedly  has,  in 
the  hands  of  the  average  operator,  a  higher  morbidity  and  is  more  likely 
to  leave  more  serious  disability,  than  cesarean  section  at  the  time 
of  election.  It  is  probable,  however,  that  pubiotomy  has  a  distinct  place 
in  patients  seen  late  in  labor,  since  in  these  cases  the  results  of  cesarean 
section  are  relatively  unsatisfactory,  even  though  no  definite  symptoms 
of  infection  are  present. 

LITEEATUEE 

Ahlfeld.     Lehrbuch  der  Geburtshiilfe.     1898. 

Klien.  Die  Geburt  beim  Kyphotischen  Becken.  Arch.  f.  Gyn.  1896. 
i:  I. 

Pestalozza,  E.  La  indicazione  del  taglio  cesareo  considerata  in 
riguardo  a  quella  della  sinfisiotomia,  della  craniotomia,  e  del  parto 
prematuro  artificiale.     Amsterdam,  1900. 

Sanger.     Der  Kaiserschnitt  bei  Uterusmyomen.     Leipzig,  1882. 

ScANZONi,  F.  W.  VON.     Compendium  der  Geburtshilfe.     Wien,   1854. 

Williams.  Pelvic  Indications  for  the  Performance  of  Cesarean  Sec- 
tion.   Am.  Med.     1901.    2:483. 

A  Case  of  Spondylolisthesis.     Am.  Jr.  Obst.     1899.     40:  145. 


CHAPTER  III 


OTHER  PELVIC  INDICATIONS 


Kyphotic  Pelvis — Spondj^lolisthetic  Pelvis — Coxalgic  Pelvis — Obliquely  Contracted 
Pelvis — Transversely  Contracted  Pelvis — Osteomalacic  Pelvis — Pelvic  Exostoses 
— Tumors  of  Pelvis — Old   Pelvic  Fractures — Bibliography. 

No  discussion  of  the  pelvis  in  relation  to  the  necessity  for  cesarean 
section  would  be  complete  without  including  the  more  uncommon  pelvic 
deformities,  due  to  abnormalities  outside  the  pelvis,  or  to  abnormalities 
of  development.  The  forms  of  pelvic  contraction  which  have  been 
under  discussion  in  the  previous  sections  have  been  due  to  some  develop- 
mental fault  in  the  pelvis  as  a  whole,  possibly  complicated  by  rachitis 
in  early  life,  or  in  other  cases  due  to  a  simple  lack  of  development,  or  to 
weight  bearing  at  a  period  of  life  when  the  bones  of  the  pelvis  were  still 
soft  and  malleable. 

Other  forms  of  deformed  pelvis  remain  for  consideration  in  which 
the  pelvic  changes,  due  to  abnormalities  in  the  development  of  certain 
of  the  pelvic  bones,  are  responsible  for  the  deformity;  or  else  it  is  pro- 
duced by  disease  in  other  portions  of  the  skeleton,  as  for  instance  in 
the  spinal  column  or  hip  joint,  which  brings  about  changes  in  the  pelvis 
owing  to  a  faulty  transmission  of  the  body  weight.  The  majority  of 
patients  who  show  these  deformities  have  some  peculiarity  of  figure  or 
of  gait,  which  should  attract  the  attention  of  the  most  careless  observer, 
and  thus  serve  as  an  indication  for  careful  examination  to  estimate  their 
importance,  although  onl}^  too  often  no  attention  is  paid  to  them. 

Kyphotic  Pelvis. — The  changes  in  the  pelvis  which  result  from  spinal 
caries  vary  according  to  the  level  at  which  the  spine  is  affected.  If  the 
deformity  is  in  the  dorsal  region,  it  is  compensated  for  by  a  marked 
lordosis  below  it,  and  the  pelvis  is  little  changed.  When  the  kyphos  is 
in  the  lumbar  region,  the  attempt  at  compensation  produces  marked 
changes  in  the  pelvis,  which  are  increased  in  degree,  the  lower  the  process. 
The  main  characteristic  of  the  pelvis  in  these  cases  is  a  marked  funnel 
shape,  the  iliac  crests  being  flared  out  and  the  ischial  spines  and  tuber- 
osities approaching  each  other.  The  effect  on  labor  is  even  more  pro- 
nounced than  in  the  ordinary  form  of  funnel  pelvis,  since  the  sacrum  is 

40 


OTHER  PELVIC  INDICATIONS 


41 


rotated  to  some  extent  on  its  transverse  axis  and  the  tip  approaches  the 
symphysis.  The  posterior  sagittal  diameter  of  the  outlet  is  thus  shortened, 
and  a  contraction  of  the  bisischial  diameter  to  less  than  8  centimeters 
in  these  cases  is  an  absolute  indication  for  a  radical  operative  delivery, 
preferably  cesarean  section,  if  the  child  is  living  and  the  patient  otherwise 
a  good  operative  risk,  since  the  anteroposterior  contraction  of  the  outlet 
renders  the  chance  of  spontaneous  delivery  in  these  cases  practically  nil, 
and  the  ordinary  operative  procedures  usually  result  in  death  of  the  child 
and  greatly  increased   risk  to  the  mother.      Pubiotomy  may   be   con- 


FlG.    16. — DORSOLUMBAR   KYPHOSIS  :    LONGITUDINAL    SECTION. 


sidered,  if  the  transverse  diameter  is  not  less  than  6  centimeters  and  the 
patient  is  a  doubtful  cesarean  risk,  owing  to  the  length  of  time  she  has 
been  in  labor  or  for  some  similar  reason.  If  the  child  is  dead,  craniotomy 
is  the  operation  of  choice,  and  if  the  patient  is  believed  to  be  infected, 
cesarean  section  followed  by  hysterectomy  will  give  the  best  results. 

When  the  lumbosacral  junction  is  the  site  of  the  disease,  the  lumbar 
vertebrae  may  collapse  forward  and  completely  block  the  pelvic  inlet, 
making  the  entrance  of  the  presenting  part  into  the  pelvis  practically 
impossible. 

The  results  of  labor  in  kyphotic  pelves  have  proved  very  unsatisfac- 
tory. The  fetal  mortality  is  given  as  between  40  and  50  per  cent  and  the 
maternal  prognosis  varies  with  the  degree  of  contraction,  being  in  one 


42 


CESAREAN  SECTION 


series  of  cases  24.3  per  cent.  Cesarean  section  at  the  time  of  election  is 
the  indicated  treatment  in  all  cases  where  the  pelvic  contraction  is  at  all 
marked,  and  I  believe  it  to  be  the  elective  procedure  in  all  cases  in  which 
any  reasonable  doubt  exists  as  to  the  possibility  of  a  pelvic  delivery. 


Fig.  17. — Pelvis  Obtecta. 


Spondylolisthetic  Pelvis. — This  rare  deformity  has  a  very  serious 
effect  on  labor,  if  it  is  at  all  marked.    In  slight  cases  it  modifies  the  course 


Fig.  18. — Spondylolisthesis. 


of  labor  much  as  does  a  flat  pelvis,  but  in  marked  cases  the  entrance  of 
the  presenting  part  into  the  pelvis  is  seriously  interfered  with  by  the 
displaced  lumbar  vertebrae  which  overhang  the  pelvic  brim.  If  the 
pseudoconjugate   diameter   in  these   cases  is  under  eight   centimeters, 


OTHER  PELVIC  INDICATIONS 


43 


cesarean  section  is  the  operation  of  election,  since  the  delivery  of  an 
average  sized  child  through  a  pelvis  of  this  size  is  practically  impossible. 
If  the  pseudocon jugate  diameter  is  more  than  eight  centimeters,  spon- 
taneous delivery  is  sometimes  possible.  This  variety  of  deformed  pelvis 
is,  however,  so  rare  that,  if  an  arbitrary  limit  of  nine  centimeters  is  set 
for  the  limit  of  spontaneous  labor,  and  all  patients  with  a  pseudoconju- 
gate  diameter  less  than  that  are  submitted  to  cesarean  section,  very  few 
mistakes  will  occur. 


Fig.   19. — Woman  with  Spondylolisthesis. 

Coxalgic  Pelvis. —  Hip  disease,  occurring  in  early  life,  gives  rise  to 
an  obliquely  contracted  pelvis.  If  the  disease  begins  before  the  child 
has  learned  to  walk,  or  if  the  child  is  confined  to  its  bed  for  a  considerable 
length  of  time,  the  diseased  side  of  the  pelvis  shows  definite  atrophic 
changes  and  is  distinctly  smaller  than  the  other  half  of  the  pelvis. 

When  the  child  begins  to  stand  the  body  weight  is  transmitted  in  great 
part  to  the  well  leg,  either  because  of  the  shortening  of  the  diseased  leg 
or  from  fear  of  pain  as  a  result  of  throwing  weight  upon  it.  The  pelvis 
thus  becomes  obliquely  tilted,  the  well  side  being  the  higher.  The  in- 
creased force  transmitted  to  the  well  leg  tends  to  push  that  side  of  the 
pelvis  upward,  inward,  and  backward,  and  an  oblique  contraction  re- 


44 


CESAREAN  SECTION 


suits,  which  involves  both  the  superior  and  inferior  straits.  Not  un- 
commonly ankylosis  of  the  sacro-iliac  joints  occurs.  As  a  rule  the, 
oblique  contraction  is  found  on  the  well  side  of  the  pelvis,  but  when  the 
diseased  leg  is  ankylosed  in  a  position  of  abduction  and  internal  rotation 
the  reverse  is  said  to  be  the  case. 

Oblique  contraction  of  the  pelvis  also  occurs  in  cases  of  one-sided 
congenital  dislocation  of  the  femur,  though  usually  to  a  less  degree  than 
in  disease  of  the  hip,  and  similar  changes  may  occur  in  untreated  uni- 
lateral infantile  paralysis  or  in  cases  of  shortening,  due  to  disease  of 
the  knee  or  ankle,  or  after  amputation. 


Fig.  20. — CoxALGic  Pelvis  with  Ankylosed  Femur. 

The  possibility  of  serious  pelvic  contraction  can  hardly  be  overlooked 
in  these  cases,  since  the  patient  shows  a  pronounced  limp  on  walking. 
If  questioning  elicits  the  information  that  the  condition  has  existed  since 
early  childhood,  it  is  probable  that  pelvic  examination  will  show  atrophy 
of  the  diseased  side  of  the  pelvis  in  combination  with  oblique  contraction 
of  the  well  side.  Careful  examination  will  give  accurate  information  as 
to  the  nature  of  the  deformity,  but  its  effect  on  labor  can  only  be  esti- 
mated by  careful  exploration  of  the  cavity  of  the  pelvis  under  anesthesia, 
which  may  be  difficult,  since  the  diseased  leg  may  be  ankylosed  in  such 
a  position  as  to  interfere  seriously  with  the  necessary  manipulations.  The 
ordinary  pelvic  measurements  are  of  no  value  in  estimating  the  degree 
of  contraction,  and  those  suggested  by  Nagele  for  use  in  oblique  con- 
traction will  not  give  the  full  information  required,  although  they  will 
afford  some  help.  Fortunately  the  degree  of  contraction  is  seldom  ex- 
treme, but  serious  interference  with  labor  may  occur.  The  deformity 
involves  the  inferior  as  well  as  the  superior  strait,  and  the  position  of 


OTHER  PELVIC  INDICATIONS 


45 


the  ankylosed  leg  may  interfere  seriously  with  operative  procedures  un- 
dertaken to  deliver  the  patient. 

If  examination  under  anesthesia  demonstrates  the  fact  that  engage- 
ment is  improbable,  an  elective  cesarean  is  indicated,  as  it  is  also  in 
multiparae  with  a  history  of  previous  dystocia.  If  thefe  seems  to  be 
no  serious  obstruction  to  engagement,  if  the  child  is  not  larger  than  the 
average,  and  if  the  outlet  is  not  seriously  contracted,  it  is  probable  that 
delivery  through  the  pelvis  will  occur  and  the  case  should  be  left  to  nature, 
under  careful  observation.  In  these  cases  a  modified  test  of  labor,  con- 
ducted under  careful  asepsis,  will  often  determine  the  proper  treatment 
of  the  case.     If  after  four  or  five  hours  of  good  first  stage  labor,  the 


Fig.  21. — Pelvis   Obliquely  Contracted  from  Tension  of  Dis- 
located Femur. 


head  shows  no  sign  of  entering  the  pelvis,  the  conservative  policy  should 
be  abandoned  and  the  patient  delivered  by  the  abdominal  route. 

Obliquely  Contracted,  or  Nagele  Pelvis. — This  form  of  contracted 
pelvis  is  of  very  rare  occurrence,  but  causes  serious  dystocia  in  the  ma- 
jority of  instances,  when  found.  The  main  characteristics  are  an  oblique 
contraction,  involving  both  the  brim  and  outlet,  combined  in  most  cases 
with  ankylosis  of  the  sacro-iliac  joint  on  the  affected  side.  The  cause 
of  the  pelvic  deformity  is  a  lack  of  development,  or  even  practical 
absence,  of  the  sacral  alae  on  one  side,  which  results  in  an  oblique  con- 
traction. The  patients  do  not  limp,  and  the  ordinary  pelvic  measure- 
ments do  not  show  the  degree  of  contraction.     The  attendant's  attention 


46 


CESAREAN  SECTION 


should  be  called  to  the  presence  of  some  abnormality  by  the  fact  that  one 
iliac  crest  is  higher  than  the  other,  and  that  a  more  or  less  marked 


Fig.  22. — Pelvis  Obliquely  Contracted  (from  in  front). 

scoliosis  is  present,  when  further  investigation  will  reveal  the  deformity. 
Since  careful  examination  of  the  pregnant  woman  is  the  exception  and 


Fig.  23. — Pelvis  Obliquely  Contracted  (from  behind). 

not  the  rule,  most  cases  pass  unrecognized  till  the  development  of  dystocia 
calls  for  careful  investigation.  The  importance  of  early  recognition  is 
considerable,  because  in  all  but  slight  cases  delivery  through  the  pelvis 


OTHER  PELVIC  INDICATIONS  47 

is  impossible  and  pubiotomy  is  out  of  the  question,  owing  to  the  ankylosis 
of  the  sacro-iliac  joint.  In  marked  degrees  of  contraction  either  cesarean 
section  or  craniotomy  is  necessary  for  delivery,  and  the  former  is  in- 
dicated whenever  the  deformity  is  discovered  during  pregnancy  or  at  a 
period  of  labor  which  does  not  contraindicate  abdominal  delivery. 

Transversely  Contracted,  or  Robert  Pelvis. — This  form  of  con- 
tracted pelvis  is  seen  when  the  sacral  alae  on  both  sides  are  imperfectly 
developed.  Examination  shows  that  all  the  transverse  measurements 
are  markedly  shortened,  while  the  anteroposterior  measurements  are 
practically  unchanged.  It  is  an  exceedingly  rare  form  of  contracted 
pelvis,  but  in  all  reported  cases  the  transverse  narrowing  has  been  so 
great  as  to  render  the  birth  of  a  living  child  impossible.     Cesarean  sec- 


FiG.  24. — Pelvis  Transversely  Contracted. 


tion  at  the  time  of  election,  if  the  condition  is  discovered  as  it  should  be 
before  the  onset  of  labor,  is  the  only  rational  treatment. 

Osteomalacic  Pelvis. — Osteomalacia  is  a  very  rare  disease  in  this 
country,  but  occurs  sufficiently  often  so  that  every  obstetrician  of  large 
hospital  experience  is  liable  to  meet  with  an  occasional  case.  Since  the 
vertebral  column  and  pelvis  are  the  portions  of  the  skeleton  most  af- 
fected, it  has  a  special  importance  obstetrically,  particularly  since  the 
pelvic  change  increases  in  repeated  pregnancies,  so  that  instead  of  labor 
becoming  easier  it  may  eventually  become  impossible  and  require  cesarean 
section  for  delivery. 

The  history  of  these  patients  is  usually  quite  characteristic  and  aids 
greatly  in  the  diagnosis  of  the  condition.  The  parturient  woman,  usually 
a  multipara,  complains  of  muscular  symptoms,  generally  involving  the 
iliopsoas  muscles,  associated  with  rheumatoid  pains.    The  same  symptoms 


48 


CESAREAN  SECTION 


recur  with  increased  severity  in  each  succeeding  pregnancy  and  labor  is 
more  difficult  than  ever  before.  If  pregnancy  again  occurs,  the  pains 
become  more  severe  and  locomotion  is  so  interfered  with  that  for  the 
last  months  of  pregnancy  the  patient  is  bedridden  and  craniotomy  or 
cesarean  section  is  necessary  at  the  time  of  labor. 


Fig.  25. — Osteomalacic  Pelvis  (from  above). 

Shortly  after  delivery  the  pains  disappear,  and  when  the  patient  is 
able  to  be  up  and  about  again  she  notices  she  is  some  inches  shorter  than 


Fig.  26. — Osteomalacic  Pelvis  (from  below). 

previously,    and   at   times   kyphotic   changes   develop    in   the   vertebral 
column. 

The  changes  in  the  pelvis  depend  entirely  on  the  degree  of  softening 
of  the  pelvic  bones.  In  the  early  stages  of  the  disease  a  simple  flattening 
results.  In  the  later  stages,  when  the  bones  have  become  very  soft,  the 
pelvic  cavity  becomes  so  compressed  by  the  pressure  of  the  body  weight 


OTHER  PELVIC  INDICATIONS  49 

that  labor  is  impossible.  The  pelvis  may  take  on  almost  any  shape,  ac- 
cording to  the  direction  in  which  pressure  is  transmitted  to  it.  In  all 
but  early  cases,  in  which  the  pelvic  change  is  slight,  cesarean  section  is 
the  operation  of  choice,  followed  by  removal  of  the  ovaries,  since  this 
procedure  is  said  to  be  successful  in  producing  a  cure  of  the  disease, 
although  its  effect  may  be  simply  that  of  preventing  further  progress  by 
rendering  pregnancy  impossible. 

Atypical  Pelvic  Deformities. — In  rare  cases  the  pelvis  may  be  more 
or  less  deformed  by  the  presence  of  exostoses  at  various  points,  and 
less  frequently  by  tumor  formation. 

Exostoses. — Exostoses  most  frequently  occur  on  the  posterior  sur- 
face of  the  symphysis,  just  in  front  of  the  sacro-iliac  synchondroses,  or 
upon  the  anterior  surface  of  the  sacrum.  In  very  rare  cases  they  may 
be  found  along  the  iliopectineal  line.  In  exceptional  cases  they  may  be 
of  sufficient  size  to  cause  a  serious  obstruction  to  labor,  but  their  effect 
is  more  likely  to  be  that  of  causing  injury  to  the  maternal  soft  parts, 
and  several  cases  have  been  reported  in  which  they  have  cut  through  the 
lower  uterine  segment  and  have  caused  serious  hemorrhage,  or  even  death. 
If  they  seem  to  be  of  sufficient  size  to  cause  dystocia,  or  sharp  enough 
to  endanger  the  maternal  soft  parts,  cesarean  section  offers  the  safest 
means  of  delivery. 

Tumors  of  the  Pelvis. — Tumor  formations  of  various  kinds  may 
arise  from  the  walls  of  the  true  or  false  pelvis  and  reach  such  proportions 
as  to  render  labor  impossible.  Enchondromata  are  the  most  common 
variety,  but  fibromata,  osteomata,  carcinomata,  and  osteosarcomata 
have  been  described.  The  dystocia  depends  principally  on  the  size  of 
the  tumor  and  the  degree  to  which  it  obstructs  the  pelvic  cavity.  The 
growth  is  apt  to  be  rapid  during  the  pregnancy,  and,  therefore,  the 
degree  of  obstruction  can  only  be  properly  estimated  shortly  before  the 
beginning  of  labor. 

Before  the  introduction  of  cesarean  section  in  the  treatment  of  these 
cases,  50  per  cent  of  the  mothers  and  89  per  cent  of  the  children  are 
said  to  have  perished.  Cesarean  section  is,  therefore,  indicated  in  all 
cases  in  which  the  cavity  of  the  pelvis  is  markedly  obstructed  by  a  new 
growth;  and  in  less  marked  cases,  in  which  a  trial  of  labor  may  be  al- 
lowed, the  progress  of  the  case  should  be  most  carefully  watched,  and  if 
there  seems  to  be  any  doubt  as  to  the  passage  of  the  head  through  the 
pelvis  after  a  few  hours  of  laljor,  section  should  be  promptly  resorted  to. 

Old  Pelvic  Fractures. — Tn  rare  instances  healed  fractures  of  the 
pelvis  may  render  delivery  through  the  pelvis  absolutely  impossible.    The 


50  CESAREAN  SECTION 

obstruction  may  be  due  either  to  excessive  callus  formation,  or  to  pro- 
jection of  the  broken  ends  of  the  bones  into  the  pelvic  cavity.  This 
cause  of  dystocia  is  a  very  uncommon  one,  owing  to  the  comparative 
rarity  of  fractures  of  the  pelvis  and  to  the  frequency  with  which  such 
patients  succumb  to  the  internal  injuries  which  accompany  the  fracture 
of  the  pelvis,  so  that  comparatively  few  survive  and  fewer  still  become 
pregnant. 

The  effect  on  labor  depends  on  the  location  of  the  fracture,  the 
degree  of  callus  formation,  and  the  displacement  of  the  ends  of  the  bones. 
The  ordinary  pelvic  measurements  give  little  or  no  clue  to  the  internal 
conditions,  and  the  pelvis  should  be  thoroughly  palpated  under  anesthesia, 
if  necessary,  to  determine  the  degree  of  obstruction.  In  all  cases  in 
which  any  doubt  as  to  the  result  of  labor  exists  cesarean  section  is  the 
operation  of  election. 


LITEEATUEE 

Barbour.     Spinal   Deformity   in   Relation  to    Obstetrics.     Edinburgh, 

1883. 
Breisky.     tjber  den  Einfluss  der  Kyphose  auf  die  Beckengestalt.  Ztschr. 

d.  Gslsch.  d.  Arzt.     Wien,  1865. 
Chiari.     Spondylolisthesis.    Bui.  J.  Hopk.  Hosp.     191 1.    22:41. 
Fehling.    Pelvis  obtecta.    Arch.  f.  Gyn.     1872.    4:1. 

tJber    Wesen   und    Behandlung    der    Puerperalen    Osteomalacie. 

Arch.  f.  Gyn.     1891.    39:  171. 

GoLDTHWAiT.     The  Lumbosacral  Articulation.     Bost.   Med.   Surg.  Jr. 

191 1.     164:365. 
Kerr.     Diagnosis  and  Treatment  of  Contracted  Pelves.     Tr.  Am.  Gyn. 

Soc.      191 1.     ;^6. 
Klien.     Die  Geburt  beim  Kyphotischen  Becken.     Arch.  f.  Gyn.      1896. 

50:1. 
Latzo.       Beitrage    zur    Diagnose    und    Therapie    der    Osteomalacie. 

Monschr.  f.  Gebh.  u.  Gyn.     1897.    6:  571. 
Leopold.     Das  Skoliotische  und  Kyphoskoliotische  Rachitische  Becken. 

Leipzig,  1879. 

Weitere  Untersuchungen  iiber  Skoliotische  und  Kyphoskoliotische 

Rachitische  Becken.     Arch.  f.  Gyn.     1880.     16:1. 

LiTZMANN.     Die  Formen  des  Beckens.     Berlin,  1861. 

Nagel.     Zur  Lehre  von  der  Atresia  der  Weiblichen  Genitalien.     Verhl. 

d.  Deutsch.  Gesel.  f.  Gebh.  u.  Gyn.     1896.     34:381. 
Nagele,  H.  F.  J.     Das  Weibliche  Becken.     Carlsruhe,  1825. 


OTHER  PELVIC  INDICATIONS  51 

Treub.     Recherches  sur  le  bassin  cyphotique.     Leyden,    1889. 

Veit.     Uber  Haematosalpinx  bei  Gynatresia.     Berl.  Klin.  Woch.     1896. 

33  •■  343- 
Williams.     Pelvic  Indications  for  the  Performance  of  Caesarean  Sec- 
tion.   Tr.  Am.  Gyn.  Soc.     1901.    26:  260. 


CHAPTER  IV 

NON-PELVIC    INDICATIONS    FOR   CESAREAN    SECTION 

Cesarean  Section  in  Pelvic  Obstruction  Not  Due  to  the  Pelvis  Itself — Tumors  of  the 
Uterus — Fibromyomata — Carcinoma  of  the  Cervix — Tumors  of  Other  Organs — 
Ovarian  Tumors — Prolapse  of  Kidney  or  Spleen — Echinococcus  Cysts — Tumors  of 
Bladder — Tumors  of  Rectum — :Atresia  of  Birth  Canal — Vulva — Vagina — Cervix 
■ — Uterine  Displacements — Anteflexion — Retroflexion — Dystocia  Following  Opera- 
tions for  Uterine  Displacements — Cesarean  Section  on  Account  of  Previous  In- 
cision of  Uterus — Bibliography. 

When  cesarean  section  was  first  recognized  as  an  operation  which 
could  be  legitimately  performed  as  an  elective  procedure,  instead  of  as 
an  operation  of  last  resort,  its  employment  for  some  time  was  limited 
to  cases  in  which  no  other  means  of  securing  a  living  child  was  believed 
possible,  and  pelvic  obstruction  was  the  one  indication  which  was  con- 
sidered to  justify  its  performance. 

With  the  progress  of  time,  increasing  experience  has  proved  it  to  be 
a  relatively,  though  not  absolutely,  safe  operation  in  properly  selected 
cases  when  performed  under  proper  conditions,  until  at  the  present  time 
it  is  recognized  that  it  may  properly  be  substituted  for  a  pelvic  delivery  in 
cases  in  which,  though  the  delivery  of  a  living  child  may  be  possible,  the 
risk  to  the  life  or  health  of  the  mother  and  the  risk  to  the  child  are 
sufficient  to  warrant  the  selection  of  abdominal  delivery,  as  being  on 
the  whole  the  safest  method  of  delivery  when  the  interests  of  one  or 
both  patients  are  considered  in  the  light  of  the  conditions  present  in 
the  given  case.  In  other  words  our  position  at  the  present  time  is  that, 
whenever  cesarean  section  offers  any  marked  advantage  to  either  patient 
over  vaginal  delivery,  cesarean  section  becomes  the  operation  of  choice. 
This  change  of  opinion  has  been  gradual,  and  one  indication  after  an- 
other has  been  added  to  the  list  of  indications  for  the  operation,  until 
at  the  present  time  scarcely  any  obstetric  complication  remains,  for 
which  cesarean  section  Is  not  enthusiastically  recommended  in  the  litera- 
ture, and  successful  cases  are  reported  to  support  the  contention  of  the 
operator.  The  unsuccessful  cases,  however,  are  apt  not  to  be  reported, 
and  the  literature  does  not  fairly  represent  the  results  of  the  operation. 

In  some  cases  cesarean  section  is  a  life  or  health  saving  operation, 
and  the  gain  to  the  patient  is  very  great;  in  others  it  is  merely  the 

52 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION  53 

lesser  of  two  evils,  the  outlook  not  being  good  in  any  case  for  a  satis- 
factory result;  and  in  still  another  group  of  cases  it  is  performed  with- 
out adequate  reason,  being  merely  the  easiest  way  out  of  a  trying  situation 
for  the  attendant,  without  due  regard  for  the  well  being  of  the  patient, 
either  present  or  future.  It  is  important,  in  undertaking  any  operative 
procedure  to  effect  delivery,  not  to  lose  sight  of  the  fact  that  it  must  be  of 
real  benefit  to  the  patient;  and  that  unless  the  patient  is  a  Catholic  no 
operation  should  be  undertaken  which  seriously  endangers  her  life  for 
the  sake  of  saving  the  child,  when  any  other  method  of  delivery  is 
possible  which  may  be  safer  for  her.  Furthermore,  the  fact  that  one 
cesarean  section  is  likely,  in  the  majority  of  cases  at  least,  to  be  fol- 
lowed by  cesarean  section  in  future  pregnancies,  should  lead  to  con- 
servatism in  regard  to  its  performance  for  temporary  indications  which 
will  probably  not  recur  in  subsequent  pregnancies. 

These  facts  should  be  borne  in  mind  in  choosing  the  method  of 
delivery  in  all  cases  in  which  there  is  a  reasonable  choice,  and  the 
operation  selected  should  be  chosen  after  careful  consideration  of  the 
pros  and  cons,  and  not  simply  as  the  operation  best  suited  to  the  ease 
of  the  operator,  which  is  today  one  of  the  leading  indications  for  the 
performance  of  cesarean  section,  with  the  result  that  many  maternal 
lives  are  sacrificed,  which  would  be  saved  if  the  proper  operation  had 
been  selected. 

Tumors  of  the  Uterus  and  Other  Pelvic  Organs. — Tumors  con- 
nected with  the  uterus  or  other  pelvic  organs  may  so  obstruct  the  pelvis 
as  to  render  the  entrance  of  the  presenting  part  impossible,  and  thus 
may  furnish  an  absolute  indication  for  abdominal  delivery. 

FiBROMYOMATA  OF  THE  Uterus. — Fibromyomata  of  the  uterus  may 
seriously  complicate  pregnancy  and  labor.  The  effect  which  they  produce 
varies  markedly  with  their  size,  number,  and  location.  Miscarriage  may 
result  from  the  associated  endometritis.  Interference  with  the  circulation 
of  the  tumors  may  cause  sloughing  at  any  period  of  pregnancy,  or  their 
rapid  growth  may  cause  pressure  symptoms  which  may  call  for  operative 
relief  before  the  baby  reaches  the  period  of  viability.  In  the  majority 
of  cases,  however,  their  effect  on  pregnancy  is  slight. 

If  a  patient  passes  through  pregnancy  without  serious  trouble,  the 
only  effect  which  fibroids  in  the  upper  portion  of  the  uterus  will  have 
on  labor  is  to  interfere  with  the  uterine  contractions  to  a  greater  or 
less  extent.  In  a  patient  with  multiple  fibroids,  with  a  rigid  undilated 
cervix,  in  whom  the  trial  of  a  few  hours  of  labor  demonstrates  the  fact 
that  the  uterine  contractions  are  too  weak  to  effect  proper  cervical  dilata- 
tion, cesarean  section  may  properly  be  considered  as  the  safest  means  of 


54  CESAREAN  SECTION 

delivery.  This  is  even  more  the  case,  since  there  is  always  a  possibility 
of  sloughing  of  the  tumors  during  the  puerperium,  and,  furthermore,  an 
operation  must  usually  be  performed  at  some  future  time  for  the  removal 
of  the  fibroids  and  the  cure  of  the  patient.  The  section  should,  in  these 
cases,  be  followed  by  a  supravaginal  amputation  of  the  uterus.  If  the 
fibroids  exert  no  influence  on  the  labor,  the  wisest  course  is  to  deliver 
the  patient  from  below  and  reserve  the  curative  operation  for  a  later 
date,  in  the  hope  that  it  may  be  rendered  unnecessary  by  the  involution 
of  the  tumors  after  delivery,  the  increase  in  the  size  of  the  tumors  during 
pregnancy  being  largely  due  to  edema,  and  not  to  actual  hypertrophy. 

Fibroids  of  the  lower  uterine  segment  or  cervix  may  so  obstruct  the 
pelvic  canal  as  to  render  the  entrance  of  the  fetal  head  into  the  pelvis 
apparently  hopeless.  In  such  a  case  it  is  wise  to  reserve  the  actual 
decision  as  to  the  best  method  of  treatment  until  the  patient  goes  into 
labor,  or  the  estimated  date  of  labor  is  reached,  since  it  is  a  matter  of 
common  experience  that  tumors  which  seem  to  block  the  pelvis  hope- 
lessly a  few  weeks  before  the  onset  of  labor  may  be  drawn  out  of  the 
pelvis  toward  the  end  of  pregnancy  and  cease  to  offer  an  obstacle  to 
delivery.  Many  cases  are  reported  in  which  the  tumor  has  remained  in 
the  pelvis  until  after  labor  has  begun,  and  then  has  been  drawn  up  out 
of  the  pelvis  under  the  action  of  the  uterine  contractions.  This  solution 
of  the  difficulty,  however,  fails  to  occur  in  the  majority  of  such  cases, 
and  the  danger  of  operation  after  prolonged  labor  is  so  greatly  increased 
that  the  wisest  course  is  to  deliver  all  such  patients  by  cesarean  section, 
when  the  tumor  so  blocks  the  pelvis  as  to  prevent  the  entrance  of  the 
presenting  part  at  the  beginning  of  labor,  the  operation  being  completed 
by  hysterectomy  or  not,  according  to  the  size  and  accessibility  of  the 
tumors  and  the  condition  of  the  patient.  Occasionally  tumors  atrophy 
and  disappear  during  the  puerperium  and  a  radical  operation  may  not 
be  necessary,  but  if  the  uterus  contains  several  good  sized  fibroids,  this 
is  hardly  to  be  expected,  and  in  any  case  the  patient  should  be  removed 
to  a  properly  equipped  hospital,  where  any  surgical  procedure  which  may 
prove  necessary  can  be  performed  under  proper  conditions. 

Carcinoma  of  the  Cervix. — Cancer  of  the  cervix,  complicating 
pregnancy,  may,  in  rare  cases,  be  a  legitimate  reason  for  a  cesarean  sec- 
tion. This  will  depend,  however,  on  the  period  of  pregnancy  at  which 
the  diagnosis  of  cancer  is  made  and  the  apparent  operability  of  the  case. 
When  the  diagnosis  is  made  early  in  pregnancy  and  the  disease  is  ap- 
parently so  limited  in  extent  that  it  seems  probable  that  the  patient  can 
be  cured  by  operation,  the  only  proper  treatment  is  a  complete  hyster- 
ectomy by  the  Wertheim  method  without  regard  to  the  pregnancy,  the 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION  55 

mother  being  the  more  important  of  the  two,  and  her  life  being  dependent 
on  the  prompt  removal  of  the  growth.  The  fact  that  cancer  increases 
rapidly  during  pregnancy  renders  the  operation  almost  an  emergency 
one,  since  the  delay  of  even  a  short  time  may  render  the  case  inoperable. 
If  the  case  seems  to  be  inoperable  when  first  seen,  the  child  becomes  the 
more  important  patient,  and  every  effort  should  be  made  to  prolong  the 
pregnancy  to  the  period  of  viability,  in  its  interests.  If  the  mother 
begins  to  fail  rapidly  after  the  child  is  viable,  but  before  full  term  is 
reached,  the  child  should  be  delivered  by  cesarean  section,  since  this 
method  is  the  safest  for  it,  and  under  the  circumstances  can  do  the 
mother  no  harm. 

If  the  disease  is  discovered  during  the  latter  part  of  pregnancy  and 
is  supposed  to  be  operable,  the  child  should  be  delivered  by  section  and 
the  uterus  removed,  in  the  attempt  to  save  both  patients.  If,  however,  the 
case  is  considered  inoperable,  the  pregnancy  should  be  allowed  to  go 
to  term  and  the  method  of  delivery  chosen  according  to  the  local  condi- 
tions. In  some  cases  the  involvement  of  the  cervix  and  vaginal  wall 
will  be  so  extensive  that  any  attempt  at  delivery  through  the  vagina  is 
likely  to  be  accompanied  by  such  extensive  laceration  and  hemorrhage  as 
to  shorten  the  life  of  the  mother,  even  if  it  is  possible  to  secure  sufficient 
dilatation  of  the  cervix  to  render  delivery  possible.  In  cases  of  this 
nature  cesarean  section  is  the  operation  of  choice  in  the  interests  of 
both  patients,  since  it  will  not  only  increase  the  safety  of  the  child,  but 
will  prolong  the  mother's  life. 

Ovarian  Tumors. — Ovarian  tumors  not  infrequently  complicate 
pregnancy  and  add  greatly  to  the  dangers  of  the  condition.  In  many 
cases  the  pedicle  becomes  twisted  during  pregnancy  and  a  prompt  opera- 
tion is  the  only  means  of  saving  the  patient's  life,  and  in  other  cases 
rupture  of  the  tumor  occurs  during  labor,  which  is  sure  to  be  disastrous, 
if  the  tumor  is  either  a  dermoid  or  of  a  malignant  type.  Owing  to  this 
fact,  it  is  generally  agreed  that  the  discovery  of  an  ovarian  tumor  in  the 
first  half  of  pregnancy  should  call  for  prompt  operation  and  its  removal, 
and  experience  shows  that  the  operation  will  not  interfere  with  the 
progress  of  pregnancy  in  the  majority  of  cases. 

When  the  tumor  is  discovered  in  the  latter  part  of  pregnancy,  the 
treatment  depends  on  the  symptoms  it  causes  and  on  its  location.  If 
the  tumor  is  free  in  the  abdominal  cavity  it  should  be  removed  promptly, 
at  any  time  previous  to  the  last  month  of  pregnancy,  and  even  then  if 
it  is  causing  any  symptoms,  since  it  is  a  constant  menace  to  the  patient. 
It  is  not  an  indication  for  cesarean  section,  unless  it  is  so  situated  as  to 
interfere  with  lator,   though  symptoms  of  twisted  pedicle  may  arise 


56 


CESAREAN  SECTION 


either  during  labor  or  during  the  puerperium,  which  will  necessitate  im- 
mediate laparotomy.  In  some  cases,  however,  the  tumor  becomes  pro- 
lapsed into  the  pelvis  in  front  of  the  presenting  part  in  such  a  manner 
as  to  effectually  prevent  the  entrance  of  the  presenting  part  and  thus 
render  a  pelvic  delivery  impossible,  unless  a  reposition  of  the  tumor  can 
be  effected.  In  some  cases  postural  treatment  by  means  of  the  kneechest 
position  will  prove  successful,  and  the  tumor  will  become  replaced  above 
the  pelvic  brim.  This  often  fails,  however,  and  the  removal  of  the 
tumor  is  necessary  to  free  the  pelvis.     Some  authorities  recommend  that 


Fig.  27. — Dystocia  from  Ovarian  Cyst. 

the  patient  be  allowed  to  go  into  labor,  laparotomy  being  performed  and 
the  tumor  removed  when  the  cervix  is  nearly  fully  dilated,  and  delivery 
then  being  effected  by  forceps  or  version.  In  some  cases,  however,  the 
tumor  will  rupture  with  disastrous  results,  if  submitted  to  the  pressure 
of  labor,  and  the  wisest  course  would  seem  to  be  to  deliver  the  patient 
by  cesarean  section  at  the  time  of  election  and  remove  the  tumor  at  the 
same  time.  A  considerable  proportion  of  these  tumors  are  either  dermoid 
cysts  or  of  a  malignant  nature,  and  to  subject  the  patient  to  the  danger 
of  rupture  of  such  tumors  is  distinctly  unwise.  For  the  same  reason 
puncture  through  the  vagina  is  absolutely  contraindicated. 

Since  laparotomy  is  indicated  for  the  removal  of  the  tumor,  the  most 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION  57 

satisfactory  treatment  for  all  ovarian  tumors  which  are  so  situated  as  to 
interfere  with  delivery  is  cesarean  section  and  ovariotomy,  and  the  re- 
sults will  be  better  under  this  method  of  treatment  than  if  the  patient  is 
allowed  to  undergo  the  exhaustion  of  a  long  labor  and  then  is  subjected 
to  a  laparotomy.  The  only  disadvantage  of  this  method  of  treatment 
lies  in  the  fact  that  the  scar  left  in  the  uterus  acts  as  a  point  of  weakness 
and  possible  rupture  in  future  pregnancies  and  labors,  and  at  the  present 
time  there  is  a  strong  feeling  among  most  surgeons  that,  if  a  patient  is 
once  delivered  by  section,  future  deliveries  are  most  safely  accomplished 
in  the  same  way.  I  personally  believe  that,  if  a  patient  has  once  been 
delivered  by  cesarean  section,  it  is  distinctly  unwise  to  allow  her  to  go  into 
active  labor  in  future  pregnancies,  although  if  the  uterine  wound  has 
been  properly  sutured  and  if  the  convalescence  has  been  absolutely 
afebrile,  the  risk  involved  is  probably  not  a  great  one ;  but  I  believe  it  to 
be  greater  than  that  of  repeated  cesarean  section  at  the  time  of  election. 

Tumors  not  Connected  with  the  Generative  Organs. — Inter- 
ference with  labor  by  tumors  not  connected  with  the  pelvis  or  generative 
tract  is  of  rare  occurrence,  but  must  be  borne  in  mind  as  a  possible  indica- 
tion for  cesarean  section. 

Kidney  or  Spleen. — Prolapse  of  normal  or  enlarged  kidney  into  the 
pelvis  may  so  obstruct  the  pelvic  cavity  that,  if  it  is  not  discovered  and 
removed  during  pregnancy,  cesarean  section  will  prove  necessary  for 
delivery,  a  small  number  of  such  cases  being  reported  in  the  literature. 
One  case  has  been  reported  in  which  a  prolapsed  spleen  was  removed 
from  the  pelvis  in  the  second  month  of  pregnancy,  thus  suggesting  that 
in  rare  instances  a  prolapsed  spleen,  which  is  not  discovered  during 
pregnancy,  may  prove  a  serious  obstruction  to  labor  and  necessitate 
cesarean  section, 

Echinocpccus  Cysts. — ^Large  echinococcus  cysts  may  occupy  the  pelvic 
cavity  and  necessitate  cesarean  section  in  very  rare  instances. 

Tumors  of  the  Bladder. — Tumors  of  the  bladder  may  sometimes 
interfere  with  the  normal  mechanism  of  labor,  but  are  rarely  large  enough 
to  call  for  radical  interference;  but  large  calculi,  unless  removed,  may 
cause  sufficient  obstruction  to  render  abdominal  delivery  necessary. 

Tumors  of  the  Rectum. — Large  tumors  arising  from  the  rectum  or 
pelvic  connective  tissue  may  so  obstruct  the  pelvis  as  to  render  cesarean 
section  necessary.  Cancer  of  the  rectum  has  had  this  effect  in  a  con- 
siderable number  of  cases,  and  other  tumors  less  frecjuently. 

Atresia  of  the  Generative  Canal. — Vulva. — Incomplete  atresia  of 
the  vulva  may  present,  in  rare  cases,  such  an  obstacle  to  delivery  that  it 
is  either  impossible  or  sure  to  be  attended  with  such  extensive  laceration 


58  CESAREAN  SECTION 

that  cesarean  section  is  the  wisest  course,  in  order  to  prevent  serious 
damage  with  its  consequent  invalidism.  This  condition  is  usually  due 
to  cicatricial  changes,  consequent  either  upon  trauma  or  upon  severe  in- 
flammatory conditions,  and  in  most  cases  the  scar  tissue  will  soften  dur- 
ing pregnancy  sufficiently  to  permit  delivery  without  too  extensive  injury. 
If,  however,  the  scar  tissue  does  not  soften  during  pregnancy,  cesarean 
section  should  be  performed  as  the  only  means  of  preventing  serious 
damage  and  the  possible  invaHdism  which  may  follow.  The  same  holds 
true  in  women  who  have  suffered  serious  injury  to  the  soft  parts  in 
previous  deliveries  and  who  have  been  subjected  to  extensive  repair 
operations,  since  delivery  per  vaginam  will  very  probably  result  in  serious 
damage,  the  repair  of  which  may  prove  unsatisfactory. 

Vagina. — Incomplete  vaginal  atresia  may  give  rise  to  serious  dystocia 
at  the  time  of  labor.  The  cases  which  cause  serious  trouble  are  almost 
always  secondary  in  origin  and  result  from  the  extensive  formation  of 
scar  tissue  following  injuries  or  inflammatory  processes.  In  the  great 
majority  of  cases  the  cicatricial  tissue  undergoes  marked  softening  during 
pregnancy,  and  the  pressure  of  the  presenting  part  after  labor  begins 
overcomes  the  obstruction  sufficiently  to  permit  of  manual  dilatation  or 
incision,  without  too  great  risk  of  serious  damage.  In  cases  in  which 
no  softening  occurs  during  pregnancy  and  the  obstruction  remains  so 
resistant  that  dilatation  seems  improbable  or  likely  to  result  in  serious 
damage  to  the  surrounding  structures,  cesarean  section  is  indicated  at 
the  onset  of  labor. 

Tumors  of  the  Vagina. — Solid  tumors  of  the  vagina  or  surround- 
ing tissues  may  offer  an  insuperable  bar  to  labor.  When  the  tumor 
is  accessible  excision  is  indicated,  but  if  the  tumor  is  first  discovered 
shortly  before  the  estimated  date  of  labor  or  during  labor,  cesarean  sec- 
tion may  be  necessary  with  removal  of  the  tumor  later. 

Cervix. — Cicatricial  stenosis  of  the  cervix  frequently  follows  lacera- 
tion occurring  during  difficult  labor  associated  with  infection  and  con- 
siderable destruction  of  tissue.  Less  frequently  it  may  be  due  to  syphilitic 
ulceration  and  induration.  In  rare  cases  it  may  result  from  the  use  of 
strongly  corrosive  substances  employed  for  the  purpose  of  producing 
abortion,  and  not  infrequently  it  may  result  from  gynecological  opera- 
tions for  the  repair  of  extensive  lacerations,  and  is  especially  liable  to 
follow  amputation  of  the  cervix,  which  is,  therefore,  an  operation  of 
doubtful  expediency  in  women  of  the  childbearing  age. 

Ordinarily  the  circulatory  changes  incident  to  pregnancy  result  in 
sufficient  softening  to  render  dilatation  at  the  time  of  labor  possible,  or 
the  stenosis  will  yield  to  dilating  bags  or  to  manual  dilatation.     In  rare 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION  59 

cases,  however,  the  rigidity  is  too  great  to  be  overcome  by  these  means, 
and  in  such  cases  cesarean  section  is  indicated  early  in  laljor,  as  soon 
as  the  condition  is  appreciated,  since,  unless  prompt  delivery  is  ac- 
complished, stretching  of  the  lower  uterine  segment  will  occur  which 
will  eventually  result  in  rupture  of  the  uterus,  when  relief  is  not  given 
by  abdominal  delivery.  In  rare  cases  complete  atresia  of  the  external  os 
may  occur,  due  of  course,  to  some  process  which  has  arisen  after  con- 
ception has  taken  place.  Cesarean  section  offers  the  only  means  of 
relief  in  such  cases. 

Occasionally  in  elderly  primiparae,  and  rarely  in  younger  women, 
true  rigidity  of  the  cervix  occurs  and  nature's  methods  of  dilatation  prove 
absolutely  ineffective.  The  condition  is  also  seen  in  an  even  more  marked 
degree  in  patients  who  have  suffered  from  inflammatory  onditions  in- 
volving the  cervix.  The  choice  of  operation  in  these  cases  lies  between 
abdominal  and  vaginal  cesarean  section  and  depends  on  the  other  con- 
ditions present,  the  size  of  the  child  and  pelvis,  the  dilatability  of  the 
vagina  and  perineum,  and  whether  the  cervix  can  be  drawn  down  to  the 
vulva  or  is  held  high  in  the  vagina  by  an  inflammatory  exudate.  If 
labor  comes  on  more  than  a  month  before  the  estimated  date  and  the 
child  is  so  small  that  vaginal  delivery  will  prove  an  easy  matter  after 
the  cervical  obstruction  is  removed,  vaginal  hysterotomy  is  the  operation 
of  choice  for  such  patients.  If,  however,  the  patient  is  at  or  near  term 
and  in  good  condition  for  cesarean  section,  this  operation  will  ordinarily 
prove  the  most  satisfactory  method  of  delivery. 

Uterine  Displacements: — Anteflexion. — In  primiparae  marked 
anteflexion  of  the  uterus  with  the  development  of  a  pendulous  abdomen 
usually  affords  evidence  of  the  existence  of  a  marked  disproportion  be- 
tween the  head  and  pelvis.  Such  a  condition  calls  for  careful  examina- 
tion before  the  onset  of  labor,  and  if  serious  disproportion  is  discovered 
cesarean  section  is  indicated  at  the  time  of  election.  In  multiparae  this 
condition  is  usually  due  to  the  relaxed  condition  of  the  abdominal  walls; 
and  since  any  dystocia  which  may  develop  is  due  to  faulty  transmission 
of  the  force  of  the  uterine  contractions  to  the  cervix,  good  results  will 
sometimes  follow  the  application  of  a  tight  abdominal  bandage  to  hold 
the  uterus  in  a  relatively  normal  position,  and  cesarean  section  is  only 
to  be  considered  in  cases  in  which  the  present  child  is  out  of  proportion 
to  the  pelvis,  it  being  larger  than  the  former  children,  or  when  a  moderate 
test  of  labor  shows  unsatisfactory  progress. 

Retroflexion. — In  the  great  majority  of  cases  in  which  the  uterus 
is  in  retroflexion  when  conception  occurs  one  of  three  results  takes  place. 
Either  the  impregnated  uterus  becomes  restored  to  its  normal  position 


6o  CESAREAN  SECTION 

spontaneously  or  by  artificial  means,  the  patient  aborts,  or  incarceration 
of  the  retroflexed  uterus  occurs  with  urgent  symptoms  which  call  for 
relief. 

In  very  rare  cases,  however,  the  pregnancy  may  go  on  to  term,  the 
fundus  of  the  uterus  remaining  attached  to  the  floor  of  the  pelvis,  while 
the  anterior  wall  hypertrophies  sufficiently  to  allow  room  for  the  develop- 
ment of  the  fetus.  In  this  condition  the  head  of  the  child  occupies  the 
fundus  of  the  uterus,  while  the  cervix  is  sharply  bent  and  drawn  upward, 
so  that  the  external  os  lies  above  the  level  of  the  symphysis.  When  labor 
begins  the  uterine  contractions  tend  to  force  the  child  through  the  most 
dependent  portion  of  the  uterus,  i.e.,  the  fundus,  and  the  cervix  dilates 
only  partially.  Spontaneous  labor  is  out  of  the  question.  In  some  cases 
the  cervix  is  fairly  easily  accessible  and  delivery  can  be  accomplished 
by  manual  dilatation  followed  by  version.  In  other  cases,  however, 
cesarean  section  offers  the  only  hope  of  delivery,  and  if  the  case  is  left 
to  nature,  death  of  the  mother  from  infection  or  rupture  of  the  uterus  is 
inevitable,  since  it  is  impossible  to  reach  the  cervix  per  vaginam  to  effect 
dilatation  and  delivery.  An  early  diagnosis  is  essential  to  success  under 
these  conditions. 

Dystocia  FoUoiinng  Operation  for  the  Relief  of  Retropositions  of 
the  Uterus. — The  recognition  of  retrodisplacements  of  the  uterus  as  a 
cause  of  ill  health  has  led  to  the  development  of  many  operations  for 
their  relief.  Several  of  these,  although  they  rectify  the  malposition,  may 
give  rise  to  serious  dystocia  if  the  patient  attempts  to  have  children  in 
the  future.  For  several  years  it  has  been  recognized  that  ventro-  and 
vaginal  fixations  of  the  uterus  are  particularly  liable  to  result  unfavor- 
ably in  future  labors,  and  it  has  more  recently  developed  that  even  a 
simple  suspension  may  occasionally  result  in  a  fixation,  even  in  the  best 
hands,  and  cause  dystocia.  Operations  of  the  Gilliam  and  Baldy  types 
seem  to  be  much  less  liable  to  cause  trouble  than  the  other  operations, 
but  I  have  seen  one  instance  in  which  such  distortion  of  the  uterus  re- 
sulted following  a  Gilliam  operation  as  to  render  cesarean  section  the 
safest  means  of  delivery,  if  not  absolutely  the  only  means. 

The  fixation  of  the  fundus  of  the  uterus  to  the  abdominal  wall  pro- 
duces various  results  during  pregnancy,  but  in  a  general  "way  the 
mechanism  of  the  dystocia  is  as  follows :  the  fundus  being  fixed  by  firm 
adhesions  which  prevent  its  mobility,  the  anterior  wall  of  the  uterus  can 
only  take  part  in  the  enlargement  necessary  for  the  accommodation  of 
the  growing  ovum,  if  the  cervix  is  drawn  up  out  of  the  pelvic  cavity,  and- 
even  then  its  development  is  only  partial.  As  pregnancy  goes  on  the 
hypertrophied  anterior  wall  is  represented  by  a  thick  mass  of  muscle. 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION 


6i 


while  the  posterior  wall  is  stretched  in  many  cases  almost  to  the  point 
of  rupture,  and  since  this  is  the  portion  of  the  uterus  which  must  act  to 
expel  the  fetus,  it  is  evident  that  the  contractions  will  often  prove  feeble 
and  inefficient  and  that  delivery  must  be  accomplished  by  operative  means. 


Fig.  28. — Dystocia  Resulting  from  Ventrosuspension. 

A.W.,  abdominal  wall;  U.W.,  uterine  wall;  Ad.,  adhesion  between  uterus 
and  anterior  abdominal  wall;  B.,  bladder;  F.,  anterior  uterine  wall,  folded; 
P.,  placenta. 

The  possibility  of  delivery  per  vaginam  depends  largely  on  the  position 
of  the  cervix.  In  some  cases  the  anterior  wall  takes  little  part  in  the 
development  of  the  uterine  cavity  and  remains  simply  a  thickened  mass 
of  muscle,  while  the  cervix  occupies  its  normal  position,  or  nearly  so. 
Such  cases  can  be  delivered  by  manual  dilatation,  followed  by  either 
forceps  or  version,  due  care  being  taken  not  to  rupture  the  distended 
posterior  wall  of  the  uterus.     In  other  cases,  perhaps  the  majority,  the 


62  CESAREAN  SECTION 

stretching  of  the  posterior  wall  exerts  marked  traction  on  the  cervix,  with 
the  result  that  some  stretching  of  the  anterior  wall  occurs,  and  the 
cervix  is  displaced  upward  and  backward,  being  sometimes  even  above 
the  level  of  the  promontory  of  the  sacrum  and  out  of  reach,  while  the 
pelvic  brim  is  obstructed  by  the  thickened  anterior  wall.  Labor  in  such 
cases  is  ineffective  and  carries  with  it  some  danger  of  rupture  of  the 
posterior  wall,  while  operative  delivery  from  below  is  practically  out  of 
the  question,  owing  to  the  inaccessibility  of  the  cervix,  which  interferes 
with  attempts  at  dilatation  and  with  extraction  of  the  fetus,  if  dilatation 
is  secured. 

Cesarean  section  is  the  operation  of  election  in  all  cases  in  which  there 
is  marked  upward  displacement  of  the  cervix,  and  may  properly  be  com- 
bined with  an  attempt  to  separate  the  adhesions  which  fix  the  uterus  to 
the  abdominal  wall.  The  greatest  care  must  be  taken  in  these  cases  to 
secure  adequate  contraction  of  the  thinned  out  posterior  wall  after  the 
extraction  of  the  child,  to  prevent  postpartum  hemorrhage,  and  the  uterus 
should  be  watched  until  proper  contraction  and  retraction  occur  before 
the  abdomen  is  closed.  Unless  proper  contraction  of  the  posterior  wall 
can  be  produced,  supravaginal  amputation  of  the  uterus  should  be  per- 
formed, since,  if  the  improperly  functioning  uterus  is  replaced  and  the 
abdomen  closed,  serious  postpartum  hemorrhage  may  follow  with  possibly 
fatal  results. 

Previous  Cesarean  Section  or  Other  Operations  on  the  Uterus. 
— "Once  a  cesarean  section,  always  a  cesarean  section"  is  a  dictum  which 
has  been  laid  down  by  some  authors  and  denied  by  others.  That  it  is 
impossible  for  any  patient  who  has  had  a  cesarean  section  to  be  delivered 
by  vagina  in  a  subsequent  pregnancy,  is  a  statement  which  is  manifestly 
absurd,  since  many  patients  have  been  delivered  either  spontaneously  or 
by  easy  forceps  operations,  and  rarely  by  version,  with  perfectly  satis- 
factory results,  when  allowed  to  go  into  labor  in  subsequent  pregnancies. 
On  the  other  hand  a  certain  small  percentage  (2-3  per  cent)  have 
suffered  rupture  of  the  uterine  scar,  either  during  pregnancy  or  labor, 
in  later  pregnancies.  When  this  accident  has  occurred  the  majority  of 
the  patients  have  died  from  hemorrhage  or  peritonitis,  but  a  sufficient 
number  have  shown  such  slight  symptoms  from  the  rupture  that  it  is 
not  possible  to  predict  that  even  rupture  of  the  uterus,  when  it  occurs, 
is  necessarily  the  dangerous  accident  in  these  cases  that  it  is  when  it 
occurs  during  labor  as  a  result  of  overstretching  of  the  lower  uterine 
segment  or  of  improper  operative  procedures.  Even  though  the  mother 
has  survived  in  these  cases,  the  child  is  almost  inevitably  lost  and  lapar- 
otomy is  usually  necessary  to  effect  delivery,  so  that  it  is  a  fair  statement 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION  63 

that  in  all  of  the  cases  in  which  rupture  occurs  a  disastrous  result  has 
followed. 

After  studying  the  scar  in  a  series  of  cases  in  which  the  uterus  had 
been  removed  for  various  reasons  at  the  time  of  a  second  cesarean  section, 
Williams  came  to  the  conclusion  that  a  well  healed  cesarean  scar  is  not  a 
menace  to  the  patient  in  later  labors,  and  that  in  some  cases  no  evidence 
of  scar  tissue  can  be  found,  even  on  microscopical  examination.  He, 
therefore,  believes  that  if  the  wound  is  properly  sutured  primarily,  and 
if  the  convalescence  is  afebrile,  showing  a  complete  absence  of  infection 
in  the  uterine  wall,  it  is  safe  to  allow  the  patient  to  go  into  labor,  always 
supposing  that  the  cause  which  rendered  the  first  cesarean  section  neces- 
sary is  no  longer  present. 

On  the  other  hand  it  is  a  common  experience,  in  performing  repeated 
cesarean  sections,  to  find  either  a  very  thin  scar  at  the  site  of  the  previous 
uterine  incision,  which  would  be  a  source  of  danger  if  labor  were  per- 
mitted, or  to  find  that  in  a  portion  of  the  old  wound  the  uterine  muscula- 
ture has  separated  and  the  fetal  membranes  or  placenta  are  covered  only 
by  peritoneum,  even  in  patients  in  whom  no  history  of  infection  of  the 
wound  at  the  previous  operation  can  be  obtained  and  when  the  previous 
operation  was  performed  by  a  competent  surgeon  so  that  there  can  be 
no  suspicion  that  careless  methods  of  suture  were  employed. 

In  the  light  of  such  conflicting  evidence,  it  is  evidently  impossible  to 
lay  down  any  definite  rule  which  can  be  applied  to  all  cases,  but  each  case 
must  be  considered  on  its  merits.  If  the  operation  is  performed  for  a 
permanent  indication,  e.g.,  for  disproportion  between  the  child  and  the 
pelvis,  the  dictum  holds  true,  unless  the  baby  is  so  much  smaller  in  the 
second  pregnancy  that  the  disproportion  no  longer  exists.  If  the  primary 
operation  was  performed  for  temporary  reasons,  e.g.,  placenta  previa  or 
eclampsia,  and  there  were  no  complications  to  point  to  a  weak  scar,  it  is 
perhaps  permissible  to  allow  the  patient  to  attempt  labor,  if  she  is  in  a 
hospital,  so  that  prompt  operation  can  be  performed' at  the  earliest  indica- 
tion of  trouble ;  but  even  in  such  cases  the  danger  to  the  patient  is,  in  my 
opinion,  such  that  I  prefer  to  deliver  every  patient  by  cesarean  section, 
if  she  has  been  previously  so  delivered,  except  when  the  patient  is  in 
active  labor  and  delivery  is  imminent  when  she  is  first  seen  by  the 
surgeon. 

In  the  cases  in  which  the  patient  has  been  in  labor  for  some  time  when 
first  seen  and  examination  shows  that  rapid  progress  has  been  made  in 
dilatation  of  the  cervix  and  that  the  presenting  part  is  well  in  the  pelvis, 
so  that  it  is  evident  that  labor  will  soon  be  terminated  if  left  to  nature, 
there  can  be  no  excuse  for  cesarean  section,  but  labor  should  be  ter- 


64  CESAREAN  SECTION 

minated  by  forceps  as  soon  as  the  cervix  is  fully  dilated,  so  as  not  to  sub- 
ject the  uterine  scar  to  the  dangers  of  the  increased  strain  of  the  second 
stage  of  labor. 

I  strongly  believe,  however,  that  cesarean  section  at  the  time  of 
election  offers  the  safest  method  of  delivery  for  patients  who  have  been 
previously  delivered  by  that  operation.  My  own  experience  has  been 
that  in  spite  of  the  evidence  in  favor  of  a  competent  scar  in  uninfected 
cases,  a  certain  number  of  scars  are  thin  and  weak,  and  I  feel  that  we 
have  nO'  means  of  predicting  the  competency  of  the  scar  in  the  individual 
patient.  This  belief  is  based  on  personal  observations  in  repeated  cesarean 
operations  on  patients  who  have  had  afebrile  convalescences  after  opera- 
tions performed  by  presumably  competent  surgeons,  and  on  reports  of 
other  cases  in  which  rupture  of  the  old  scar  has  occurred  either  during 
pregnancy  or  labor  under  similar  circumstances.  It  is  undoubtedly  true 
that  the  great  majority  of  cesarean  scars  in  such  cases  will  stand  a  labor 
of  average  severity  perfectly  well,  but  it  is  impossible  to  predict  which 
patient  will  suffer  from  uterine  rupture,  if  allowed  to  go  into  labor.  A 
sufficient  number  of  scars  do  rupture  to  constitute  a  very  real  danger, 
even  though  the  actual  percentage  is  small.  I  feel  that  the  danger  of 
rupture  is  greater  than  the  risk  of  the  repeated  operation  and,  therefore, 
believe  that  it  is  improper  to  subject  a  patient  to  a  greater  risk  when  a 
course  which  involves  a  less  risk  can  be  pursued.  I  am,  therefore,  ac- 
customed to  advise  every  patient  who  has  once  been  delivered  by  cesarean 
section  to  have  any  subsequent  pregnancies  terminated  in  the  same  way. 

There  can  be  no  question  about  the  advisability  of  such  a  course  in 
patients  in  whom  the  indication  for  the  primary  operation  is  a  permanent 
one,  since  the  reasons  which  rendered  the  first  operation  advisable  re- 
main unchanged,  and  in  fact  are  strengthened  by  the  fact  that  the  scar 
left  in  the  uterus  by  the  first  operation  affords  an  added  source  of  danger, 
if  the  patient  is  allowed  to  attempt  labor. 

In  patients  in  whom  the  primary  operation  was  done  for  some 
temporary  indication,  which  is  no  longer  present  at  the  time  of  the  second 
labor,  I  consider  the  presence  of  the  uterine  scar  a  sufficient  indication  for 
a  repetition  of  the  operation,  although  it  may  not  always  prove  necessary 
in  cases  who  have  had  an  afebrile  convalescence  following  the  first 
operation.  It  should,  however,  be  considered  obligatory  in  patients  who 
give  a  history  of  a  febrile  convalescence,  since  this  points  to  the  prob- 
ability of  uterine  Infection  and  unsatisfactory  healing  of  the  uterine  in- 
cision, and  it  Is  In  these  patients  that  the  rupture  of  the  scar  in  subsequent 
pregnancies  and  labors  is  most  to  be  feared. 

In  patients  who  are  seen  In  subsequent  labors  well  advanced  in  labor 


NON-PELVIC  INDICATIONS  FOR  CESAREAN  SECTION  65 

with  the  head  well  in  the  pelvis  and  the  cervix  fully  or  nearly  fully  dilated, 
a  repeated  cesarean  section  is  certainly  unnecessary  and  unwise,  but  the 
labor  should  be  terminated  as  promptly  as  possible  after  full  dilatation 
is  accomplished,  to  prevent  all  possible  strain  on  the  scar  and  thus  mini- 
mize any  possible  danger  of  rupture.  It  is  not  in  my  opinion  a  question 
as  to  whether  a  pelvic  delivery  may  not  be  possible  without  rupture  of 
the  uterus,  but  I  believe  that  the  fact  that  a  certain  number  of  presumably 
competent  scars  do  rupture  is  a  sufficient  reason  for  never  intentionally 
allowing  such  a  patient  to  run  the  risk  of  labor  when  conditions  are  such 
as  to  warrant  a  repeated  cesarean  section. 

A  similar  condition  exists  when  the  uterus  has  been  operated  on  for 
the  removal  of  myomata  located  deeply  in  its  substance.  If  the  tumors 
were  subserous  or  were  so  situated  that  a  fairly  thick  layer  of  normal 
muscle  remained  between  the  bed  of  the  tumor  and  the  uterine  cavity, 
there  need  be  little  or  no  apprehension  as  to  the  behavior  of  the  uterine 
scar  at  labor.  If,  however,  the  tumors  were  submucous,  so  that  the 
uterine  cavity  was  opened  or  the  endometrium  exposed  during  their  re- 
moval, there  is  sure  to  be  considerable  formation  of  scar  tissue,  just  as 
in  septic  cesarean  scars,  and  the  danger  of  rupture  late  in  pregnancy  or 
during  labor  is  markedly  increased.  These  cases  should  be  watched  most 
carefully  during  pregnancy  and  are  best  delivered  by  cesarean  section  at 
the  time  of  election,  rather  than  exposed  to  the  danger  of  rupture  of  the 
uterus  during  labor.  The  same  holds  true  for  patients  who  have  suffered 
a  rupture  of  the  uterus  in  a  previous  pregnancy  or  labor  and  have  re- 
covered to  again  become  pregnant,  although  there  are  cases  on  record 
in  which  spontaneous  delivery  without  complications  has  followed  a 
rupture  of  the  uterus  in  a  previous  labor. 

In  brief,  the  question  may  be  summed  up  by  the  statement  that  when- 
ever any  condition  exists  in  the  uterus,  which,  in  the  opinion  of  the 
attendant,  renders  cesarean  section  a  safer  method  of  delivery  for  the 
given  patient  than  a  pelvic  delivery,  cesarean  section  should  be  performed. 
Opinions  may  differ  and  equally  good  men  may  take  opposite  positions 
for  what  seem  to  them  good  and  sufficient  reasons,  but  each  operator  must 
be  guided  by  his  own  experience  and  do  what  he  conscientiously  believes 
is  best  for  the  given  patient,  and  he  will  find  authority  for  which  ever 
course  he  may  pursue.  My  own  personal  feeling  is  that,  although  in  only 
a  small  percentage  of  cases  will  the  uterine  scar  be  found  so  inefficient  as 
to  expose  the  patient  to  a  serious  danger  of  rupture,  except  when  the 
previous  convalescence  has  been  definitely  febrile,  none  the  less  the  safest 
course  for  the  patient  is  repeated  section.  When  the  original  cesarean 
indication  is  still  operative,  there  is  absolutely  no  cjuestion  as  to  the  proper 


66  CESAREAN  SECTION 

procedure,   and  a  repeated  cesarean  section  is  the  only  proper  treat- 
ment. 

LITEEATURE 

Andrews.     The  Effect  of  Ventral  Fixation  of  the  Uterus  upon  Subse- 
quent Pregnancy  and  Labour.     Jr.  Obst.  Gyn.  Brit.  Emp.     1905. 

8:97- 
Bland-Sutton.     The  Surgery  of  Pregnancy  and  Labour  Complicated 

with  Tumours.    Lancet.     1901.     i  :  382,  452,  529. 
Brodhead,   G.  L.     Cesarian  Section   for  Fibrocystic  Uterine  Tumor. 

Post-Grad.     March,   1901. 
Rupture  of  the  Uterus  through  the  Caesarean  Cicatrix.     Am. 

Jr.  Obst.    1908.    57:  650. 
Gabory,  R.     La  therapeutique  de  la  procidence  du  cordon:  I'operation 

cesarienne,  est  elle  parfois  indiquee?     Paris  Theses.     No.  477. 

1910. 
Goder.     Von  dem  Becken  ausgehende  Tumoren  als  Geburtshinderniss. 

Halle,  1895. 
HoLZAPFEL.     Kaiserschnitt  bei  Mastdarmkrebs  Beitr.  z.  Gebh.  u.  Gyn. 

1899.    2 :  59. 
Jaschke.     Megakolon  als  Geburtshinderniss.     Zentrbl.  f.  Gyn.     1915- 

P-  747. 
Lynch.     Kaiserschnitt      infolge      Ventro-fixation      und      Suspension. 

Monschr.  f.  Gebh.  u.  Gyn.     1904.     19:  521. 
RuHL.     Kritische  Bemerkungen  iiber  Geburtsstorungen  nach  Vaginal- 

fixatio  Uteri.    Monschr.  f.  Gebh.  u.  Gyn.     1901.     14:  477. 
Sanger.     Der   Kaiserschnitt   by   Uterusmyomen.     Leipzig,    1882. 
Schauta.     Myom  und  Geburt.     Compt.  Rind.   i6me.  Cong,  de  Med. 

Budapest.    1910.    7:8. 
ScHOPPiNG.     Das  Becken-enchondrom,  besonders  als  Geburtshinderniss. 

Monschr.  f.  Gebh.  u.  Gyn.     1907.    25  :  845, 
Stadfeld.     Die  Geburt  bei  Geschwiilsten  des  Beckens,     Centrbl.  f.  Gyn. 

1880.    4:417. 
Weieel.     Uber  Schwangerschaft  und  Geburt  nach  Interpositio  Uteri 

Vesico-vaginalis.     Arch.  f.  Gyn.     1916.     105:65. 
Williams.     Dystocia  following  Ventral  Suspension  and  Fixation  of  the 

Uterus.    Jr.  So.  Surg.  Gyn.  A.     1906.     19. 


CHAPTER  V 

OTHER   INDICATIONS 

Cesarean  Section  in  Toxemia  of  Pregnancy — Placenta  Previa — Separation  of  the 
Placenta — Cardiac  Disease — Poor  Physical  Equipment — Poor  Nervous  Equipment 
— Elderly  Primiparae — After  Operations  for  Repair  of  Previous  Injury — Malpo- 
sitions of  Fetus,  Breech,  Face,  Transverse — Postmortem  Cesarean  Delivery — 
Abdominal  Abortion — Bibliography. 

There  remains  for  consideration  a  group  of  indications  for  the  reHef 
of  which  cesarean  section  is  often  recommended  and  performed,  but  in 
which  the  choice  of  operation  may  be  open  to  criticism  from  so-called 
conservative  members  of  the  profession.  These  conditions  are  some- 
times temporary  in  character  and  sometimes  permanent.  The  question 
to  be  decided  in  the  individual  case  is  not  whether  cesarean  section  is 
necessary  to  effect  the  delivery  of  a  living  child,  but  rather,  whether  it 
does  not  carry  with  it  certain  advantages  to  one  or  both  patients  which 
more  than  compensate  for  the  increase  in  risk  which  is  attendant  on  any 
abdominal  operation.  The  gain  to  the  patient  may  be  increased  safety  to 
life  or  health  at  the  present  time,  or  it  may  be  simply  that,  by  eliminating 
the  strain  of  labor,  certain  complications  which  are  sure  to  arise  in  the 
future  may  be  postponed  at  a  minimum  increase  in  the  immediate  risk. 
There  is  no  question  but  that  cesarean  section  offers  the  safest  method  of 
delivery  for  the  child,  and  in  cases  in  which  the  child  is  of  paramount 
importance  it  may  be  indicated  for  this  reason  only,  as  long  as  it  does 
not  seriously  increase  the  danger  to  the  mother. 

In  considering  these  indications  it  is  well  to  state  that  disproportion 
between  the  child  and  pelvis  will  not  be  considered  as  a  factor,  although 
if  such  disproportion  exists,  it  naturally  increases  the  urgency  of  the 
other  indications,  and  they  in  turn  may  settle  the  choice  of  the  operation 
in  border  line  cases ;  but  the  question  at  issue  is  merely  to  consider  the 
advisability  of  cesarean  section  in  certain  conditions  when  it  is  admitted 
that  other  methods  of  delivery,  though  possible,  have  very  definite  dis- 
advantages. In  other  words  the  operation  may  be  performed  as  the 
wisest  method  of  meeting  a  situation  which  can  be  dealt  with  in  other 
ways. 

Toxemia  of  Pregnancy  and  Eclampsia. — It  is  oui^  of  place  in  a 

67 


68  CESAREAN  SECTION 

discussion  of  cesarean  section  to  consider  the  merits  of  the  various 
methods  of  treatment  for  such  a  compHcation  as  the  toxemia  of  preg- 
nancy, but  it  is  impossible  to  discuss  methods  of  dehvery  and  their 
relative  advantages  in  a  serious  condition  without  briefly  summarizing 
our  present  knowledge  of  the  condition  which  calls  for  relief. 

Toxemia  is  a  condition  arising  during  pregnancy  only  and,  therefore, 
dependent  to  some  extent  at  least  on  the  pregnancy.  The  exact  cause  of 
the  condition  is  unknown,  and  there  may  be  multiple  causes,  any  one  of 
which  associated  with  pregnancy  may  give  rise  to  the  disease,  if  it  may 
be  so  called.  Careful  prenatal  care  will  undoubtedly  prevent  a  large 
proportion  of  the  cases  and  will  give  an  opportunity  for  its  early  dis- 
covery and  treatment,  if  it  does  develop,  with  rather  more  than  an  even 
chance  that  all  threatening  symptoms  will  subside  promptly,  and  that, 
in  a  certain  proportion  of  the  remainder,  they  will  be  relieved  or  held  in 
abeyance,  though  not  entirely  cured.  In  a  certain  proportion,  however, 
treatment  has  no  effect,  the  toxemia  increases,  and  the  patient  is  in  im- 
minent danger  of  eclampsia,  unless  she  is  delivered  or  unless  the  baby 
dies  as  a  result  of  the  maternal  toxemia,  after  which  the  symptoms  as  a 
rule  subside,  although  in  a  small  proportion  of  cases  the  death  of  the 
child  results  in,  or  at  least  is  followed  by,  an  increase  in  the  toxemia. 

Most  of  the  cases  of  true  eclampsia  develop  in  the  group  of  patients 
who  do  not  yield  to  eliminative  treatment,  or  who  do  not  receive  adequate 
prenatal  care,  and  the  best  interests  of  the  patient  demand  the  termina- 
tion of  the  pregnancy  whenever  the  treatment  of  the  toxemia  fails.  This 
is  to  be  done  by  the  method  which  seems  to  be  the  most  conservative  one 
for  the  given  patient,  after  all  the  circumstances  in  the  individual  case 
have  been  considered.  Severe  toxemia,  unless  accompanied  by  chronic 
nephritis,  is  most  often  seen  in  primiparae  in  whom  induction  of  labot 
and  operative  delivery  is  most  apt  to  be  difficult  and  attended  by  unsatis- 
factory results  for  both  mother  and  child.  In  cases  without  pelvic  dis- 
proportion the  method  of  delivery  is  usually  to  be  selected  according  to 
the  condition  of  the  maternal  soft  parts  and  the  urgency  of  the  symptoms. 
If  the  vagina  is  not  rigid,  and  if  the  cervical  canal  is  obliterated,  so  that 
labor  may  be  easily  induced  by  the  use  of  a  dilating  bag,  or  in  favorable 
cases  by  manual  dilatation  and  delivery,  which  will  be  found  to  be  the 
case  in  the  majority  of  instances,  the  pelvic  route  is  indicated.  If,  how- 
ever, the  cervix  is  rigid  and  the  canal  not  obliterated,  so  that  pelvic  in- 
duction seems  to  promise  marked  difficulty,  and  if  the  toxemia  is  rapidly 
increasing,  either  vaginal  or  abdominal  cesarean  section  is  indicated, 
since  in  this  type  of  case  induction  of  labor  often  proves  a  slow  and  un- 
satisfactory procedure  and  time  is  an  object.     If  the  patient  is  markedly 


OTHER  INDICATIONS  69 

premature  with  a  small,  possibly  non-viable  child,  vaginal  cesarean  sec- 
tion is  the  preferable  procedure,  but  if  the  child  is  large  and  the  condi- 
tion of  the  soft  parts  is  such  that  serious  laceration  seems  inevitable,  if 
the  pelvic  route  is  selected,  abdominal  cesarean  section  offers  very  defi- 
nite advantages  for  both  patients.  This  is  particularly  true  in  elderly 
primiparse  who  may  never  have  other  children  and  to  whom  the  possible 
loss  of  the  baby  during  delivery  is  a  relatively  more  serious  matter  than 
it  would  be  to  younger  women,  although  it  is  never  fair  to  any  patient 
to  take  serious  risks  for  the  child,  no  matter  what  her  age,  when  these 
risks  can  be  avoided  without  seriously  increasing  the  danger  to  her. 

The  development  of  eclampsia  in  patients  who  are  under  efficient 
observation,  except  in  patients  who  present  no  premonitory  symptoms 
(a  very  small  class),  should  be  extremely  rare,  since  it  is  an  evidence  of 
lack  of  proper  care  or  of  lack  of  appreciation  of  the  needs  of  the  patient 
in  the  presence  of  threatening  symptoms.  There  is  a  growing  feeling 
among  authorities  who  have  followed  the  results  obtained  in  prenatal 
clinics,  that  with  proper  care  eclampsia  may  be  made  an  almost  obsolete 
condition;  but  this  can  only  be  accomplished  by  education  of  both  the 
lay  and  medical  public  to  an  understanding  of  the  mutual  advantages  to 
be  derived  from  careful  prenatal  observation  of  every  patient  and  the 
importance  of  prompt  action  in  the  face  of  threatening  symptoms.  The 
condition  is,  however,  still  sufficiently  common,  so  that  it  demands  at- 
tention. 

When  eclampsia  develops,  a  new  problem  complicates  the  situation. 
The  patient  is  admittedly  in  an  exceedingly  dangerous  condition,  due  at 
least  in  part  to  the  pregnancy,  and  best  relieved  by  the  termination  of 
the  pregnancy,  if  that  can  be  accomplished  without  adding  to  the  danger. 
The  patient  is  usually,  however,  profoundly  shocked  by  the  convulsions, 
and  it  is  a  grave  question  whether  she  can  be  delivered  by  any  operative 
means  without  increasing  the  danger  by  adding  shock  to  shock. 

There  are  two  distinct  schools  at  the  present  time  in  regard  to  the 
proper  treatment  of  eclampsia,  the  radical  and  the  conservative.  The 
radical  school  demands  immediate  delivery  of  the  eclamptic  patient  as 
soon  as  convulsions  occur,  on  the  basis  that,  since  eclampsia  is  in  some 
way  dependent  on  pregnancy,  the  only  logical  method  of  treatment  must 
include  termination  of  pregnancy  by  some  means.  Accouchement  force, 
the  dilating  bag,  vaginal  cesarean  and  abdominal  cesarean,  all  have 
their  adherents,  and  each  in  the  hands  of  certain  operators  has  given 
fairly  satisfactory  results  when  compared  with  the  results  obtained  in 
other  clinics  where  operative  delivery  is  practiced  as  a  routine,  but  the 
mortality  following  operative  treatment  of  the  patients  who  are  having 


70  CESAREAN  SECTION 

convulsions  is  so  high,  no  matter  what  method  is  used,  as  to  suggest  the 
wisdom  of  a  change  in  poHcy. 

If  the  obstetrician  is  committed  to  a  pohcy  of  immediate  deUvery  in 
all  cases  of  eclampsia,  cesarean  section  has  a  place,  though  it  should  not, 
in  my  opinion,  be  employed  to  the  exclusion  of  other  methods.  If  the 
patient  is  a  primipara,  especially  if  over  thirty-five  years  of  age,  with  a 
small,  rigid  vagina  and  a  long,  hard  cervix,  which  will  probably  resist 
attempts  at  dilatation,  by  any  means,  vaginal  cesarean  section  is  indicated 
if  the  child  is  markedly  small  and  premature,  and  abdominal  cesarean 
section  if  the  child  is  near  term  and  well  developed.  The  results  of 
operation  will  be  better  in  this  class  of  case,  if  the  patient  is  delivered 
by  cesarean  section,  than  if  she  is  subjected  to  a  difficult  or  violent  ac- 
couchement force,  but  the  maternal  mortality  will  still  be  high  enough  to 
prove  that  the  operation  is  by  no  means  a  panacea. 

In  the  last  few  years  the  statistics  of  cesarean  section  for  eclampsia 
have  improved  markedly,  the  mortality  having  progressively  dropped 
from_  75  per  cent,  as  reported  by  Halbertsma  in  the  early  series  of  cases, 
until  at  the  present  time  it  is  little,  if  any,  higher  than  the  mortality 
obtained  by  other  operative  measures,  between  20  per  cent  and  30  per 
cent,  and  is  definitely  lower  than  this  in  properly  selected  cases  of  the 
type  of  patient  described  above. 

In  eclampsia,  occurring  in  patients  in  whom  the  cervical  canal  is 
obliterated  and  the  external  os  relatively  soft  and  easily  dilatable,  cesarean 
section  has  no  place,  since  the  induction  of  labor  on  appropriate  cases, 
and  even  accouchement  force,  will  give  equally  good  results  and  will 
leave  the  patient  in  a  condition  to  have  normal  labors  in  future  preg- 
nancies. 

The  members  of  the  conservative  school  claim,  and  statistics  would 
seem  to  support  them,  that  while  it  is  undoubtedly  logical  to  end  the 
pregnancy,  if  it  can  be  done  without  killing  the  patient,  the  shock  of 
an  operative  delivery  in  any  patient  already  shocked  by  repeated  con- 
vulsions may  turn  the  scale  against  her  and  result  in  death,  when  a 
more  conservative  policy  might  succeed  in  saving  her  life.  They  claim 
that  in  most  cases  labor  will  be  initiated  by  the  convulsions  and  that  by 
waiting  for  labor  and  treating  the  toxemia  in  the  meantime,  instead  of 
operating  on  every  patient  at  the  earliest  possible  moment,  many  lives 
will  be  saved ;  and  this  view  is  supported  by  the  published  statistics,  al- 
though the  mortality  still  remains  fairly  high,  varying  from  6.6  per  cent 
to  10  per  cent  in  different  series  of  cases.  This  mortality  is  probably 
largely  dependent  on  the  toxemia  which  is  the  underlying  cause  of 
eclampsia  and  will  never  be  materially  lowered  until  eclampsia  is  prac- 


OTHER  INDICATIONS  71 

tically  eliminated  by  prenatal  care,  and  by  the  delivery  of  all  cases  of 
toxemia  in  which  prophylactic  treatment  fails  l^efore  the  toxemia  pro- 
duces enough  organic  damage  to  cause  the  death  of  the  patient. 

The  true  place  of  cesarean  section  in  eclampsia  is  in  those  patients 
who  do  not  start  in  labor  in  spite  of  the  convulsions,  who  are  getting 
steadily  worse  in  spite  of  treatment,  and  in  whom  the  condition  of  the 
soft  parts  renders  operation  from  below  more  dangerous  than  abdominal 
section  on  account  of  the  greater  shock  involved  in  accouchement  force 
or  the  prolonged  irritation  of  the  cervix,  plus  the  increased  absorption 
of  the  toxins  in  cases  where  a  dilating  bag  is  employed.  The  results  of 
cesarean  section  in  these  cases  will  show  a  relatively  high  mortality, 
but  in  the  aggregate  many  lives  will  probably  be  saved. 

The  prevention  of  eclampsia  by  careful  prenatal  work  and  the  de- 
livery of  the  patient  before  convulsions  occur  by  the  most  conservative 
method,  which  will  sometimes  be  cesarean  section,  holds  out  the  greatest 
hope  for  improvement  in  results.  It  is  hardly  to  be  expected  that  the 
results  of  abdominal  surgery  on  patients  who  are  thoroughly  toxic  and 
whose  power  of  excretion  is  reduced  to  a  minimum  will  ever  be  such  as 
to  render  cesarean  section  a  proper  routine  operation  for  all  cases,  but 
there  are  certain  patients  for  whom  it  is  undoubtedly  the  most  conserva- 
tive procedure. 

Placenta  Previa. — The  bad  results  which  have  attended  the  treat- 
ment of  complete  or  nearly  complete  placenta  previa,  when  in  the  hands 
of  any  but  trained  obstetricians,  has  led  many  surgeons  to  recommend 
the  performance  of  cesarean  section  in  the  treatment  of  this  condition  as 
a  routine  procedure,  in  the  hope  of  improving  the  results  for  both  mother 
and  child.  There  is  absolutely  no  doubt  but  that  the  results  obtained  in 
the  treatment  of  placenta  previa  in  the  community  as  a  whole  are  un- 
satisfactory, to  say  the  least,  but  the  underlying  cause  of  the  bad  results 
is  not  the  method  of  treatment,  so  much  as  the  delay  in  treatment,  as 
the  following  statement  of  facts  shows.  In  general  practice  uterine 
bleeding  suggestive  of  the  presence  of  a  placenta  previa  is  treated  ex- 
pectantly, a  positive  diagnosis  of  the  cause  being  rarely  made.  As  a 
result  the  maternal  mortality  is  very  high,  being  ordinarily  quoted  as 
36  per  cent.  The  results  obtained  in  the  treatment  of  the  same  types  of 
patients  in  hospital  practice  under  the  care  of  trained  obstetric  specialists 
present  a  marked  contrast,  the  mortality  varying  from  one  to  four  per 
cent,  according  to  the  reports  of  different  clinics,  and  these  figures  in- 
clude the  patients  sent  to  the  hospital  in  extremis  as  well  as  the  cases 
which  arise  in  the  hospital  clinic  itself. 

Such  a  discrepancy  suggests  what  is  undoubtedly  true,  that  the  gen- 


^2  CESAREAN  SECTION 

eral  practitioner  is  not  equipped  to  deal  with  such  an  emergency  as 
placenta  previa,  and  either  uses  poor  judgment  in  his  selection  of  opera- 
tive methods  or  operates  unskillfully,  and,  therefore,  loses  many  patients 
unnecessarily.  While  both  of  these  hypotheses  are  to  a  certain  extent 
true,  the  real  underlying  factor  in  the  problem  is  found  in  the  prompti- 
tude with  which  the  symptoms  which  point  to  the  existence  of  a  serious 
condition  are  recognized  and  met. 

In  private  practice  the  attendant  is  prone  to  neglect  the  warnings 
afforded  by  slight  uterine  bleeding  and  defers  active  measures  until  the 
occurrence  of  severe  hemorrhage  forces  him  to  deliver  a  patient  who  is 
no  longer  in  proper  condition  to  withstand  the  shock  of  a  severe  opera- 
tion, with  the  result  that  many  patients  are  lost  who  might  have  been 
saved  by  prompt  treatment.  In  hospital  practice  and  among  trained 
obstetric  surgeons  the  importance  of  prompt  diagnosis  of  the  cause  of 
uterine  hemorrhage  in  the  latter  half  of  pregnancy  is  recognized  and, 
therefore,  the  majority  of  cases  of  placenta  previa  come  to  operation  in 
relatively  good  condition  with  every  reason  to  expect  a  successful  out- 
come. 

The  great  majority  of  cases  of  placenta  previa  are  best  treated  either 
by  a  Braxton-Hicks  version,  or  induction  of  labor  by  means  of  a  large 
dilating  bag,  as  soon  as  the  diagnosis  is  made.  A  few  cases,  such  for 
instance  as  a  primiparae  in  whom  the  hemorrhage  is  profuse,  the  cervix 
rigid,  and  the  canal  not  obliterated,  are  best  treated  by  cesarean  section. 
This  combination  occurs  very  seldom,  since  as  a  rule  the  cervix  is  soft, 
though  friable,  in  placenta  previa.  It  may  be  met  with  in  primiparae 
in  whom  placenta  previa  is  rare,  or  in  multiparae  when  the  cervix  is  the 
seat  of  excessive  scar  tissue  formation,  either  secondary  to  inflammatory 
conditions  or  extensive  operative  procedures.  It  is  extremely  doubtful 
whether  cesarean  section  would  improve  the  maternal  mortality  to  any 
great  extent,  since  the  results  of  the  other  methods  of  treatment  are 
satisfactory,  if  the  patient  is  in  fair  condition  when  the  operation  is 
undertaken.  This  is  usually  the  case,  unless  the  initial  hemorrhage  has 
been  unusually  profuse  or  the  warning  signs  have  been  neglected,  and 
the  performance  of  an  abdominal  operation  on  patients  suffering  from 
acute  anemia  as  the  result  of  repeated  hemorrhages  cannot  be  expected 
to  give  entirely  satisfactory  results.  It  is  probable  that  the  routine 
adoption  of  cesarean  section  in  the  treatment  of  placenta  previa  will  re- 
sult in  an  increased,  rather  than  in  a  decreased  mortality. 

The  keynote  of  success  is  prompt  delivery  by  what  seems  to  be  the 
most  conservative  method  for  the  individual  case  before  the  patient  has 
lost  enough  blood  to  be  in  a  serious  condition.     It  is  undoubtedly  true 


OTHER  INDICATIONS  73 

that  in  patients  who  have  their  initial  hemorrhage  when  at  or  near  term, 
and  in  whom  examination  shows  a  large  child  whose  relation  to  the  pelvis 
is  doubtful,  cesarean  section  is  indicated  as  the  operation  of  election,  in 
case  the  mother  is  in  good  condition.  These  cases  are  comparatively 
uncommon,  however,  since  in  the  great  majority  of  cases  the  initial 
hemorrhage  in  complete  placenta  previa  occurs  before  the  eighth  month 
of  pregnancy  at  a  time  when  only  extreme  pelvic  contraction  would  re- 
sult in  disproportion  between  the  child  and  pelvis. 

Some  writers  urge  that  the  claims  of  the  unborn  child  deserve  con- 
sideration and  that  cesarean  section  will  do  much  to  lower  the  fetal 
mortality.  This  is  extremely  doubtful,  however,  owing  to  the  fact 
that  the  initial  hemorrhage  in  complete  or  nearly  complete  placenta 
previa  usually  occurs  at  a  time  when  the  child  is  either  non-viable  or 
markedly  premature.  In  these  cases  no  method  of  delivery  can  give  a 
great  improvement  in  the  fetal  mortality,  and  the  routine  adoption  of 
cesarean  section  as  the  method  of  delivery  will  probably  result  in  a  slight 
improvement  in  fetal  mortality  and  a  distinct  increase  in  maternal 
mortahty.  If  the  child  is  at  or  near  term  when  the  emergency  is  recog- 
nized, more  children  will  undoubtedly  be  saved  by  cesarean  section  than 
by  other  means,  but  not  if  the  child  is  markedly  premature,  and  since  the 
latter  is  the  rule  rather  than  the  exception,  there  is  little  chance  that 
routine  cesarean  section  will  greatly  lower  the  fetal  mortality. 

The  sponsors  of  cesarean  section  in  placenta  previa  base  their  claims 
as  to  the  advantages  of  the  operation  largely  on  a  comparison  with  the 
results  obtained  by  accouchement  force  in  patients  who  have  been  allowed 
to  have  repeated  hemorrhages.  When  a  comparison  is  made  between 
the  results  of  cesarean  section  and  the  use  of  the  dilating  bag  or  Braxton- 
Hicks  version,  all  performed  on  patients  who  are  delivered  as  soon  as 
the  diagnosis  is  made,  cesarean  section  will  have  no  better  and  very 
probably  worse  results,  except  in  selected  cases,  and  its  adoption  as  a 
routine  procedure  is  more  likely  to  result  in  losing  rather  than  in  saving 
lives.  It  is  only  fair  to  say,  however,  that  various  German  authorities 
have  enthusiastically  adopted  this  procedure  as  a  distinct  advance  in  the 
treatment  of  these  cases.  Cesarean  section  is,  in  my  opinion,  only  indi- 
cated in  the  treatment  of  placenta  previa  when  the  cervix  is  rigid  and  its 
canal  is  not  obliterated,  or  in  patients  at  or  near  term  when  the  child 
is  apparently  out  of  proportion  to  the  pelvis. 

Premature  Separation  of  the  Normally  Situated  Placenta. — Con- 
cealed or  accidental  hemorrhage  is  one  of  the  most  dangerous  complica- 
tions of  pregnancy  and  laljor,  practically  all  of  the  children,  and,  accord- 
ing to  Goodell,  50  per  cent  of  the  mothers  being  lost.    If  the  hemorrhage 


74  CESAREAN  SECTION 

is  mostly  external,  the  prognosis  is  largely  dependent  on  the  amount  of 
blood  lost,  but  the  fact  must  be  borne  in  mind  that  comparatively  slight 
external  bleeding  may  be  accompanied  by  serious  intra-uterine  hemor- 
rhage, and  any  patient  in  whom  the  symptoms  of  hemorrhage  are  out 
of  proportion  to  the  amount  of  external  bleeding  should  be  looked  on 
as  an  emergency  for  whom  delivery  is  urgent.  It  must  be  remembered 
also  that  in  a  certain  number  of  these  patients  the  uterine  musculature  is 
practically  disintegrated  by  the  hemorrhage  into  it,  and  that  after  de- 
livery these  patients  may  die  from  postpartum  hemorrhage,  due  to  the 
atonic  condition  of  the  uterus,  while  in  other  cases  a  degree  of  unrecog- 
nized intraperitoneal  hemorrhage  occurs  before  and  after  delivery  which 
is  sufficient  to  prove  fatal,  unless  checked  by  the  removal  of  the  uterus. 

In  severe  cases  the  mother  can  only  be  saved  by  a  prompt  emptying 
of  the  uterus,  which  should  be  accomplished  by  the  method  which  seems 
to  be  most  conservative  for  the  individual  case.  In  patients  in  whom 
labor  has  begun  and  is  going  on  in  a  satisfactory  manner,  so  that  the 
cervical  canal  is  obliterated  and  the  os  partly  dilated,  the  case  may  be 
left  to  nature,  unless  the  symptoms  are  urgent,  although  careful  observa- 
tion should  be  maintained  in  order  that  an  increase  in  the  amount  of  the 
internal  bleeding  may  be  met  by  prompt  delivery.  In  the  great  majority 
of  cases,  however,  the  placental  separation  occurs  before  labor  begins 
and  cesarean  section  offers  the  most  conservative  method  of  delivery, 
since  it  not  only  involves  less  shock  than  a  prolonged  manual  dilatation 
followed  by  version,  but  it  also  affords  the  operator  an  opportunity  to 
inspect  the  uterus  and  to  remove  it,  if  it  is  found  to  be  so  atonic  from  dis- 
integration of  its  musculature  due  to  hemorrhage  into  its  substance  that 
postpartum  hemorrhage  is  probable,  or  if  bleeding  is  going  on  into  the 
peritoneal  cavity.  It  is  fair  to  say  that  in  all  cases  in  which  the  uterus 
has  taken  on  the  ligneous  feel,  which  is  so  characteristic  in  these  cases, 
abdominal  delivery  is  the  most  conservative  treatment,  even  though  the 
cervix  is  partly  dilated,  on  account  of  the  freedom  of  action  which  it 
affords,  since  the  uterus  can  be  removed  or  conserved  at  will  after  care- 
ful inspection  and  the  patient's  Hfe  thus  saved  when  she  might  otherwise 
succumb  to  postpartum  hemorrhage,  if  delivered  per  vaginam.  In  the 
same  category  should  be  placed  the  exceedingly  rare  case  in  which  rupture 
of  a  uterine  varix  occurs  during  pregnancy  or  labor,  causing  symptoms 
of  internal  hemorrhage. 

Cardiac  Complications  of  Pregnancy. — Heart  disease  complicating 
pregnancy  and  labor  offers  a  wide  field  for  the  employment  of  cesarean 
section.  In  these  cases  we  have  an  opportunity,  not  only  of  saving  the 
patient's  life  in  the  immediate  present  by  substituting  the  short  strain 


OTHER  INDICATIONS  75 

on  the  heart  involved  in  a  laparotomy  for  the  prolonged  strain  of  labor, 
but  also  of  preserving  her  health  in  many  cases  and  preventing  her  from 
becoming  a  cardiac  invalid  for  at  least  a  considerably  longer  period  than 
v^ould  otherwise  be  the  case.  The  strain  of  pregnancy  has  been  thor- 
oughly demonstrated  to  be  so  serious  in  patients  with  cardiac  lesions  that 
pregnancy  is  recognized  as  contra-indicated  in  severe  cases,  and  the  strain 
of  labor  has  an  even  more  harmful  effect.  It  is,  therefore,  important  for 
these  women,  if  they  attempt  to  have  children,  that  they  should  be  safe- 
guarded by  every  possible  means,  and  that  delivery  should  be  made  as 
easy  as  possible  for  them  and  should  involve  as  little  strain  on  the  heart 
as  possible,  in  order  to  minimize  cardiac  damage  to  the  utmost. 

Valvular  Lesions. — It  has  long  been  recognized  that  patients  suf- 
fering from  certain  valvular  lesions  of  the  heart  stand  pregnancy  badly 
in  many  instances  and  are  apt  to  die  during  or  after  labor,  or  at  the  best 
be  left  more  or  less  permanently  invalided.  The  prognosis  is  so  grave 
in  cases  of  mitral  stenosis,  alone  or  combined  with  other  lesions,  that 
some  authorities  consider  abortion  justifiable  as  the  only  sure  method  of 
avoiding  serious  cardiac  damage.  The  aortic  lesions  come  next  in  order, 
while  mitral  regurgitation  is  relatively  mild  in  its  effects.  In  all  cardiac 
patients  the  most  conservative  advice  would  be  undoubtedly  that  preg- 
nancy should  be  absolutely  avoided,  since  the  increased  work  thrown 
on  the  heart  during  pregnancy  exhausts  its  reserve  to  some  extent  and, 
therefore,  ultimately  must  shorten  the  patient's  life,  even  if  it  does  not 
leave  her  a  cardiac  invalid.  The  effect  of  labor  on  such  a  heart  is  even 
more  serious  and  many  patients  die  or  are  left  as  cardiac  invalids  as  a 
result  of  a  labor  which  has  been  conducted  without  regard  to  their  needs. 

The  problem  that  confronts  the  obstetrician  is  a  difficult  one  when 
such  a  patient  comes  to  him  for  care,  since  she  has  been  placed  in  a 
position  which  inevitably  involves  a  lowering  of  her  cardiac  reserve  to 
some  extent,  and,  which,  even  if  it  does  not  produce  immediately  serious 
consequences,  is  sure  to  cause  some  permanent  damage,  which  can  only 
be  minimized  by  extreme  care  during  pregnancy  and  by  the  adoption 
of  the  method  of  delivery  which  involves  the  least  strain  on  the  heart. 

As  a  general  rule  it  may  be  said  that  any  patient  with  mitral  stenosis 
or  an  aortic  lesion  who  has  at  any  time  suffered  from  cardiac  decompen- 
sation, no  matter  how  slight,  should  be  looked  on  as  a  bad  risk  for 
labor  and  as  in  a  serious  condition  throughout  pregnancy.  She  should 
be  treated  as  an  invalid  throughout  pregnancy,  kept  under  most  careful 
observation,  and  delivered  by  cesarean  section  at  the  time  of  election, 
in  the  hope  of  reducing  the  amount  of  cardiac  damage  to  a  minimum : 
and  in  order  to  prevent  her  from  taking  similar  risks  in  the  future,  it  is 


7^6  CESAREAN  SECTION 

distinctly  advisable  that  she  should  be  sterilized  at  the  time  of  the  opera- 
tion. The  fact  that  the  heart  has  decompensated  at  some  time  is  absolute 
evidence  that  the  patient  is  in  a  precarious  condition  and  should  receive 
the  most  careful  attention. 

Any  primipara  with  mitral  stenosis  or  an  aortic  lesion  should  be 
delivered  by  cesarean  section,  even  though  she  may  never  have  had  a 
failure  in  compensation,  in  order  to  minimize  the  depletion  of  the  cardiac 
reserve,  since  in  many  cases  prolonged  or  permanent  invalidism  has 
followed  labor,  even  though  it  was  not  unduly  difficult.  Sterilization 
is  not  necessarily  indicated  in  these  cases  unless  the  patient  requests  it, 
since  if  the  patient  has  developed  no  cardiac  symptoms  during  pregnancy 
and  desires  other  children,  she  may  be  allowed  to  have  them,  on  the 
understanding  that  each  successive  pregnancy  will  lessen  her  cardiac 
reserve  to  some  extent  and  therefore  shorten  her  life,  although  practical 
invalidism  during  pregnancy  and  cesarean  section  at  term  will  reduce 
the  damage  to  a  minimum.  Patients  suffering  from  mitral  regurgitation 
are  in  much  less  serious  danger,  and  if  the  heart  has  never  shown  any 
signs  of  decompensation,  may  be  allowed  to  go  into  labor,  the  second 
stage  being  cut  short  by  early  operative  delivery. 

Multiparae  with  well  compensated  mitral  stenosis  or  aortic  lesions 
may  be  allowed  to  go  into  labor,  since  the  strain  of  the  usually  short 
first  stage  will  not  as  a  rule  throw  an  undue  strain  on  the  heart.  They 
should,  however,  be  carefully  watched,  and,  if  any  sign  of  cardiac  failure 
occurs,  should  be  delivered  promptly  by  the  most  conservative  method, 
which  will  probably  be  cesarean  section,  if  the  cervix  is  at  all  rigid  and 
only  partly  dilated.  If  the  patient  has  at  any  time  previously  had  signs 
of  decompensation,  cesarean  section  at  the  time  of  election  will  prove 
in  many  cases  a  life  saving  procedure. 

Myocarditis. — The  condition  of  the  heart  muscle  is  even  more  im- 
portant than  the  presence  of  a  valvular  lesion,  and  patients  who  are 
believed  to  be  suffering  from  myocarditis,  whether  acute  or  chronic, 
are  better  risks  for  cesarean  section  than  for  labor,  since  a  prolonged 
difficult  labor  not  infrequently  results  in  acute  cardiac  dilatation,  which 
is  always  serious  and  may  prove  fatal.  These  patients  often  suffer  from 
symptoms  due  to  a  lack  of  cardiac  response  during  pregnancy.  Most  of 
them  are  flabby  muscularly  and  anemic,  owing  to  their  inability  to  take 
sufficient  exercise  in  the  open  air  to  keep  up  their  general  condition,  due 
partly  to  cardiac  discomfort  and  partly  to  the  necessity  of  throwing  no 
avoidable  strain  on  the  heart.  Shortness  of  breath  is  common,  and  the 
heart  action  is  often  irregular,  the  pulse  often  varying  from  20  to  50 
beats  on  minor  exertion,  although  the  heart  sounds  are  normal.    These 


OTHER  INDICATIONS  ^j 

cases  are  very  common  following  acute  infections,  such  as  influenza,  oc- 
curring during  pregnancy,  the  burden  of  pregnancy  preventing  the  heart 
muscle  from  being  restored  to  its  normal  condition,  since  the  complete 
rest  of  the  heart  necessary  to  accomplish  this  cannot  be  obtained,  owing 
to  the  increasing  burden  which  pregnancy  throws  on  the  heart.  Cesarean 
section  in  these  cases  affords  a  means  of  preventing  a  strain  on  the 
damaged  muscle,  which  may  cause  permanent  damage,  and  thus  will 
often  prove  a  health  saving,  if  not  a  life  saving  procedure. 

Poor  Physical  Equipment. —  Closely  analogous  to  the  patients  who 
present  an  actual  myocarditis,  are  the  patients  who  are  physically  poorly 
equipped  for  the  burden  of  labor,  although  they  show  no  actual  lesions 
to  attract  the  attention  of  the  obstetrician.  They  are  usually  frail,  anemic 
women,  and  the  history  of  the  past  life  suggests  that,  although  perhaps 
never  actually  sick,  they  are  never  actually  well.  In  these  women  the 
burdens  of  their  ordinary  life  seem  to  be  all  that  they  can  bear,  and 
although  never  actually  breaking  under  the  strain,  the  break  seems  al- 
ways imminent.  These  patients  usually  react  badly  to  pregnancy  and  do 
not  improve  in  physical  condition  as  pregnancy  goes  on.  If  such  women 
are  subjected  to  the  strain  of  a  hard  labor,  they  are  often  left  in  such 
an  exhausted  condition  that  a  prolonged  period  of  invalidism  follows, 
and  they  may  never  regain  their  normal,  though  feeble  health.  Cesarean 
section  offers  to  such  patients  a  means  of  conserving  energy  which  is 
vitally  important  to  them  and  should  be  seriously  considered  in  women 
of  this  type  as  a  means  of  avoiding  the  chronic  ill  health  that  is  so 
often  induced  by  a  labor  of  not  more  than  average  severity.  Undoubtedly 
the  immediate  risk  to  life  is  slightly  greater  than  that  of  delivery  by 
vagina,  but  the  advantages  to  be  gained  as  regards  future  health  by  a 
slightly  increased  risk  to  life  are  very  real. 

Poor  Nervous  Equipment. — Closely  related  to  these  patients,  and 
yet  in  a  different  group,  are  the  patients  whose  nervous  equilibrium  is 
unstable,  women  whose  past  history  shows  a  lack  of  resistance  to  the 
nervous  influences  of  their  environment.  It  is  not  uncommon  to  find 
patients,  a  large  part  of  whose  adult  life  has  been  spent  In  taking  rest 
cures  for  nervous  exhaustion,  fancied  or  real,  whose  margin  of  safety 
from  a  serious  nervous  collapse  is  extremely  small.  Such  women  are 
very  prone  to  respond  badly  to  the  strain  of  labor,  and  to  them  pain 
is  a  real  evil.  They  represent  in  our  civilized  communities  a  type  which 
would  have  been  largely  eliminated,  if  medical  care  had  not  interfered 
with  the  law  of  the  survival  of  the  fittest.  Experience  leads  me  to 
believe  that,  if  this  type  of  patient  is  subjected  to  the  strain  of  pregnancy, 
and  especially  of  labor,  neither  she  nor  her  physician  of  the  moment 


78  CESAREAN  SECTION 

will  cease  to  regret  it.  I  say  advisedly  "physician  of  the  moment," 
because  she  wanders  from  doctor  to  doctor  in  search  of  mental  health 
which  cannot  be  given.  If  such  a  patient  is  allowed  to  go  into  labor, 
it  may  be  months  or  years  before  she  recovers  from  the  shock  to  her 
nervous  system,  and  a  prolonged  attack  of  nervous  prostration  is  often 
the  sequel.  These  women  fortunately  stand  the  shock  of  an  operation 
remarkably  well  as  a.  rule.  What  they  cannot  recover  from  is  a  long 
strain,  particularly  if  much  pain  accompanies  it,  and  all  pain  is  exagger- 
ated to  them.  They  seem  to  react  especially  well  to  cesarean  section, 
which,  by  eliminating  the  pain  of  labor  as  well  as  relieving  them  of  the 
burden  of  pregnancy,  leaves  them  in  a  peculiarly  favorable  condition 
for  recuperation,  at  least  in  part,  and  they  often  leave  the  obstetrician's 
care  in  better  condition  than  he  found  them  in,  if  treated  in  this  way. 

It  may  seem  radical  to  urge  a  major  operation  to  avoid  nervous 
strain,  especially  to  those  who  do  not  meet  this  type  of  patient  in  their 
local  communities ;  but  I  am  satisfied  that  these  patients  are  the  abnormal 
product  of  an  overcivilization  and  are  much  like  hothouse  plants  and 
must  receive  special  treatment.  If  they  are  treated  as  ordinary  patients, 
the  results  are  seldom  satisfactory  to  either  doctor  or  patient. 

Elderly  Primiparae. —  It  is  very  common  to  hear  of  patients  who, 
being  pregnant  for  the  first  time  in  the  late  thirties  or  early  forties,  have 
been  allowed  to  go  into  labor  which  has  proved  unsatisfactory,  and  have 
then  been  subjected  to  a  brutal  pelvic  operation,  with  the  result  that  the 
child  is  lost  and  the  patient  so  badly  lacerated  that  secondary  operation 
has  been  necessary  to  restore  her  even  partially  to  health,  the  time  lost 
sometimes  precluding  the  possibility  of  another  pregnancy,  so  that  she  is 
thus  left  childless.  This  poHcy  is  a  relic  of  traditional  obstetrics,  which 
presupposes  that  any  woman  who  becomes  pregnant  must  have  her  child 
in  the  natural  way,  and  works  a  very  grave  injustice  to  a  class  of  women 
to  whom  one  living  child  represents  all  that  they  can  ask  for.  I  am  far 
from  advocating  that  every  elderly  primipara  should  be  delivered  by 
cesarean  section,  but  I  do  believe  that  the  ordinary  rules  which  govern 
the  choice  of  method  of  delivery  should  be  widely  extended  in  these  cases, 
and  that  if,  after  careful  examination,  any  abnormality  can  be  found, 
if  the  head  remains  high,  even  though  the  pelvis  is  normal,  or  if  the' 
soft  parts  are  sufficiently  rigid  to  suggest  the  probability  of  serious 
laceration,  the  patient  should  be  given  the  opportunity  of  having  a 
cesarean  section  if  she  so  desires,  the  increased  safety  to  the  child  and 
the  avoidance  of  laceration  being  the  principal  advantages  to  be  gained. 
If  it  is  decided  to  allow  such  a  patient  to  go  into  labor,  the  progress 
should  be  carefully  watched,  and  if-  the  uterus  functions  improperly  or 


OTHER  INDICATIONS 


79 


if  the  cervix  does  not  dilate  as  it  should,  the  so-called  conservative  policy 
should  be  abandoned  and  the  patient  delivered  promptly  by  section. 
Manual  dilatation,  followed  by  forceps  or  version,  in  these  cases  offers 
so  great  an  increase  in  the  risk  to  fetal  life  and  maternal  health  that 
cesarean  section  is  a  conservative  operation  by  comparison,  and  its  per- 
formance will  save  many  such  women  from  prolonged  ill  health  and 
from  the  regrets  of  a  childless  old  age. 

Cesarean  Section  to  Prevent  Pelvic  Damage  Following  Opera- 
tions for  Repair  of  Previous  Injury. — It  not  infrequently  happens  that 
women  who  have  suffered  serious  laceration  in  previous  labors  and 
have  undergone  extensive  operations  for  repair  of  the  injuries  again 
become  pregnant,  and  the  question  arises  as  to  how  such  patients  should 
be  delivered,  in  order  to  give  the  best  possible  results.  Certain  facts 
are  evident.  The  normal  vaginal  tissues  have  been  largely  replaced  by 
scar  tissue  as  the  result  of  the  operation,  and  scar  tissue  is  less  likely  to 
stretch  well  during  delivery  than  normal  tissue.  In  addition,  the  patient 
has  suffered  sufficiently  from  the  lesions  caused  by  the  previous  labors 
to  be  willing  to  undergo  an  extensive  operation  for  repair,  and  the 
probability  is  that  delivery  per  vaginam  will  result  in  damage  at  least 
as  serious  and  possibly  more  so  than  occurred  in  the  previous  deliveries, 
owing  to  the  abnormal  conditions  left  after  operation. 

The  principal  factors  to  be  taken  into  consideration  in  such  cases  are 
the  nature  of  the  injury  in  the  previous  labor,  the  amount  of  scar  tissue 
and  the  degree  of  softening  which  it  undergoes  under  the  influence  of 
the  increased  congestion  of  pregnancy,  and  the  degree  of  inconvenience 
suffered  by  the  patient  before  being  operated  upon.  If  the  previous 
labor  resulted  in  injury  to  the  bladder  or  rectum,  the  danger  of  re- 
currence with  the  possibility  that  a  satisfactory  result  may  not  be  ob- 
tained at  a  second  operation  warrants  the  performance  of  a  cesarean  sec- 
tion, in  place  of  subjecting  the  patient  to  the  inconvenience  and  ill 
health  consequent  on  such  an  accident. 

If  the  previous  damage  has  resulted  in  prolapse  of  the  vaginal  walls 
Virith  cystocele  and  rectocele  and  possibly  prolapse  of  the  uterus,  the 
extensive  operation  for  repair  necessarily  leaves  a  large  amount  of  scar 
tissue  in  the  vagina.  If  this  scar  tissue  becomes  succulent  and  softened 
during  pregnancy,  there  is  a  fair  chance  that  a  pelvic  delivery  may  oc- 
cur without  serious  damage,  but  if  the  patient's  health  has  suffered 
severely  during  the  interval  1>etween  the  laceration  and  the  operation  for 
repair,  it  will  be  wiser,  in  most  cases,  to  deliver  the  patient  by  section 
rather  than  subject  her  to  a  possible  recurrence  of  the  ill  health,  which 
can  be  relieved  only  by  a  secondary,  operation,  which  may  or  may  not 


8o  CESAREAN  SECTION 

prove  a  success.  If  the  scar  tissue  remains  rigid  in  spite  of  the  increased 
congestion,  it  is  almost  certain  that  serious  laceration  will  occur  if  pelvic 
delivery  is  attempted,  the  repair  of  which  may  not  prove  a  success,  and 
delivery  by  cesarean  section  offers  the  best  method  of  delivery  when  all 
factors  in  the  problem  are  considered. 

It  cannot  be  claimed  in  these  cases  that  cesarean  section  is  at  all  a 
necessary  operation  for  delivery,  but  that  it  is  the  wiser  course  when 
everything  is  taken  under  consideration,  since  it  is  a  good  working 
principle  in  obstetrics  that  abnormal  patients  are  best  treated  in  an 
abnormal  way,  and  that  the  attempt  to  treat  them  as  if  they  were  normal 
will  meet  with  disaster  in  many  instances.  The  preservation  of  health 
is  only  secondary  to  the  preservation  of  life,  and  when  health  can  be 
practically  promised  at  a  slight  increase  in  the  risk  to  life,  that  risk  is 
worth  taking. 

Cesarean  Section  in  Malpositions  of  the  Fetus. — Within  the  last 
few  years  certain  writers  have  advocated  cesarean  section  in  almost  all 
cases  in  which  the  fetus  presents  in  any  other  way  than  by  the  vertex. 
Breech,  face,  and  transverse  presentations  have  all  been  cited  as  being 
indications  for  cesarean  operation,  largely,  it  seems  to  me,  because  it  is 
an  easier  method  for  the  operator  and  requires  less  technical  skill  and 
judgment  for  successful  delivery. 

It  is  perfectly  possible  that  cesarean  section  may  prove  the  best 
method  of  treatment  in  many  of  these  cases,  but  the  indication  is  the 
cause  that  produces  the  malposition  rather  than  the  malposition  itself, 
considered  in  relation  to  the  other  conditions  present  in  the  given  case. 

Breech  Presentations. — In  primiparae  breech  presentations  have 
a  bad  reputation,  owing  to  the  difficulty  of  determining  whether  the  size 
of  the  fetal  head  is  out  of  proportion  to  the  maternal  pelvis,  and  to  the 
fact  that  the  proper  care  of  breech  presentations  involves  a  degree  of 
judgment  as  to  when  or  whether  extraction  should  be  undertaken,  and 
so  much  skill  in  its  performance  that  an  average  fetal  mortality  of  lo 
per  cent  occurs.  This  mortality  is  much  less  in  skilled  hands,  since  it 
is  largely  due  to  unwise  attempts  at  delivery,  through  an  imperfectly 
dilated  cervix.  If  the  breech  is  not  in  the  pelvis  at  the  beginning  of 
labor,  and  if  the  baby  is  unusually  large,  or  if  the  pelvis  is  contracted, 
cesarean  section  may  properly  be  considered,  but  the  indication  is  not  so 
much  the  breech  presentation  as  the  other  factors  which  are  present  in 
the  case,  such  as  disproportion  between  the  child  and  the  pelvis,  early 
rupture  of  the  membranes,  and  unsatisfactory  dilatation  of  the  cervix. 

In  multlparae  cesarean  section  is  practically  never  indicated  for 
breech  presentations  per  se  in  the  absence  of  other  indications. 


OTHER  INDICATIONS  8i 

Face  Presentations. — Primary  face  presentations  occurring  in 
primiparae  almost  always  indicate  sufficient  disproportion  between  the 
head  and  the  pelvis  to  warrant  the  belief  that  some  obstruction  exists 
which  prevents  the  entrance  of  the  head  into  the  pelvis.  Careful  exami- 
nation, especially  under  anesthesia,  will  reveal  the  facts,  and  cesarean  sec- 
tion may  very  properly  be  the  indicated  procedure,  if  such  disproportion 
is  marked.  If,  however,  as  is  usually  the  case,  the  face  presentation  de- 
velops during  labor,  the  problem  is  not  so  clear.  Even  in  these  cases  there 
may  be  definite  disproportion  in  cases  in  which  the  head  remains  high  and 
does  not  enter  the  pelvis  and  the  proper  treatment  can  only  be  determined 
by  careful  examination.  If  the  face  seems  to  be  entering  the  pelvis,  a 
moderate  test  of  labor  should  be  given,  the  progress  being  followed  by 
rectal  examination.  If  progress  is  unsatisfactory,  especially  in  posterior 
positions  of  the  face,  examination  under  ether  will  indicate  the  proper 
treatment,  but  if  good  progress  is  made,  a  pelvic  delivery  is  indicated. 

In  multiparae,  whose  previous  obstetric  history  is  normal,  a  face 
presentation  is  seldom  or  never  a  complication  which  will  call  for 
abdominal  delivery. 

Transverse  Presentations. — ^Transverse  presentations  in  primi- 
parae, except  in  multiple  pregnancies,  are  an  indication  of  sufficient  pelvic 
contraction  to  warrant  the  assumption  that  cesarean  section  is  probably 
the  best  method  of  delivery,  since  the  disproportion  between  the  head 
and  pelvis  is  usually  marked  in  these  cases.  Furthermore,  an  operative 
delivery  is  necessary  in  all  cases  at  term  and  the  danger  to  the  life  of  the 
child  and  the  soft  parts  of  the  mother  is  sufficient  to  cause  anxiety  on  the 
part  of  the  attendant.  Both  patients,  therefore,  have  an  improved  prog- 
nosis in  abdominal  delivery. 

In  multiparae  with  a  normal  obstetrical  history  cesarean  section  will 
seldom  be  the  operation  of  choice  and  practically  never,  on  account  of 
the  malposition,  if  uncomplicated  by  other  conditions  which  may  indicate 
an  abdominal  delivery. 

Postmortem  Cesarean  Section. — Although  cesarean  section  was 
originally  employed,  at  least  as  far  as  authentic  records  show,  for  the 
purpose  of  delivering  women  who  died  in  the  latter  portion  of  pregnancy, 
either  in  the  hope  of  obtaining  a  living  child,  or  so  that  mother  and 
child  might  be  buried  separately,  it  is  at  present  comparatively  rarely 
performed.  The  latter  indication,  i.e.,  the  separate  burial  of  mother 
and  child,  seems  to  have  lost  its  force  under  the  Christian  era,  and  the 
operation  is  now  performed  only  occasionally  on  the  dead  and  then  for 
the  sake  of  possibly  preserving  the  fetal  life. 

Living  children  have  been  delivered  up  to  one  hour  after  the  mother's 


82  CESAREAN  SECTION 

death,  and,  therefore,  it  would  seem,  theoretically  at  least,  as  if  some 
attempt  should  be  made  to  save  the  child,  in  case  of  maternal  death, 
after  the  period  of  viability  has  been  reached. 

Experience  has  shown,  however,  that  in  cases  of  maternal  death, 
accompanied  by  gradual  respiratory  failure,  as  in  pneumonia,  or  after 
a  lingering  illness,  the  death  of  the  child  precedes  that  of  the  mother  by 
a  considerable  interval,  owing  to  interference  with  its  supply  of  oxygen, 
and  that  the  operation  is  useless  in  such  cases.  If,  however,  the  mother 
dies  suddenly,  as  for  instance  from  heart  failure,  or  as  the  result  of  an 
accident,  the  chance  of  obtaining  a  living  child  by  operative  means 
should  be  taken. 

One  fact,  however,  must  be  borne  in  mind,  and  that  is,  the  possibility 
that  the  diagnosis  of  death  may  be  a  faulty  one  and  that  the  patient  may, 
in  rare  instances,  recover.  This  possibility  makes  it  incumbent  on  the 
operator  to  take  adequate,  though  perhaps  hurried,  aseptic  precautions, 
even  at  some  risk  of  inviting  failure,  to  avoid  the  somewhat  remote  but 
possible  contingency  of  saving  the  child  at  the  expense  of  the  mother's 
life,  in  case  the  diagnosis  of  death  should  be  erroneous.  Aseptic  prepara- 
tion of  the  patient  and  operator  should,  therefore,  be  made,  if  proper 
facilities  are  at  hand,  so  that  the  mother  may  not  recover  from  apparent 
death  to  die  of  infection. 

Such  a  patient  may  very  properly  be  delivered  by  cesarean  section, 
if  conditions  proper  for  the  operation  are  available,  and  the  complete 
operation  should  be  performed,  the  uterine  incision  being  sutured  just 
as  in  the  ordinary  operation. 

If  it  is  not  possible  to  provide  for  a  properly  aseptic  laparotomy,  it  is 
advisable  that  the  operation  should  not  be  undertaken,  and  some  authori- 
ties feel  that,  even  though  such  provision  is  made,  a  rapid  dilatation  of 
the  cervix,  followed  by  version  and  extraction,  is  the  preferable  method 
of  delivery.  The  tissues  of  a  patient  shortly  after  death  are  usually  so 
relaxed  and  flabby  that  delivery  from  below  may  be  expected  to  be  ac- 
complished as  rapidly  as  abdominal  delivery.  This  method  has  the  ad- 
vantage of  being  less  likely  to  do  harm  in  case  the  diagnosis  of  maternal 
death  is  incorrect,  unless  full  aseptic  precautions  are  observed  in  the 
abdominal  delivery ;  but  in  cases  in  which  marked  cicatricial  changes  are 
present  in  the  cervix  it  may  prove  difficult  and  cesarean  section  be  dis- 
tinctly the  better  procedure. 

Abdominal  Abortion. — By  the  term  abdominal  abortion  I  refer  to 
the  termination  of  pregnancy  before  the  period  of  viability  is  reached, 
by  abdominal  hysterotomy,  rather  than  by  the  more  usual  methods  of 
performing  abortion.     This  operation  may  be  indicated  in  any  case  in 


OTHER  INDICATIONS  83 

which  abortion  is  urgently  demanded  by  some  serious  maternal  com- 
plication and  in  which  sterilization  is  considered  indicated  to  protect 
the  patient  against  the  dangers  of  future  pregnancies. 

This  operation  is  most  often  indicated  in  patients  who  are  suffering 
from  cardiac  lesions  which  have  resulted  in  decompensation  at  some 
previous  time,  either  when  the  patient  was  not  pregnant,  during  previous 
pregnancies,  or  in  the  early  months  of  the  present  pregnancy,  and  who 
are  showing  symptoms  of  a  fresh  decompensation.  In  these  cases  the 
cardiac  condition  is  often  such  that  it  seems  probable  the  patient  either 
may  not  survive  the  present  pregnancy,  or  that,  if  she  does,  she  will  be 
left  a  cardiac  invalid  during  the  remainder  of  her  life,  and  that  another 
pregnancy  is  almost  sure  to  prove  fatal.  The  choice  of  operation  de- 
pends on  the  patient's  condition  at  the  time  and  on  the  fact  that  pregnancy 
should  never  be  attempted  again. 

If  the  patient's  condition  is  so  precarious  that  all  possible  shock 
must  be  avoided  in  terminating  the  pregnancy,  it  is  probable  that  de- 
livery from  below,  under  spinal  anesthesia,  will  prove  a  slightly  safer 
operation;  but  such  an  operation  only  partially  meets  the  indications  in 
tiiese  cases,  since  it  leaves  the  patient  in  a  condition  in  which  there  is 
danger  of  future  pregnancies,  even  though  great  care  may  be  used  to 
avoid  conception.  For  the  complete  protection  of  the  patient  sterilization 
is  necessary,  and  this  can  best  be  accomplished  by  laparotomy. 

If  the  patient  is  in  fair  condition  at  the  moment,  the  best  treatment 
is  laparotomy,  removal  of  the  ovum  through  a  uterine  incision  followed 
by  sterilization,  or  supravaginal  amputation  of  the  uterus  without  in- 
cision, as  may  be  deemed  advisable.  As  a  rule,  however,  the  latter 
operation  is  more  severe  and  carries  with  it  somewhat  greater  shock 
than  the  former. 

In  patients  with  chronic  nephritis  who  give  a  history  of  repeated 
miscarriage  or  premature  labors  with  dead  children  abdominal  abortion 
and  sterilization  is  a  justifiable  procedure.  In  these  patients  the  chance 
of  a  living  child  is  very  slight,  since  the  previous  misfortunes  are  directly 
dependent  on  a  chronic  disease  which  is  steadily  increasing,  and  each 
attempt  at  pregnancy  increases  the  renal  damage  to  some  extent  and 
leaves  the  patient  in  a  worse  condition  than  before,  thereby  shortening 
her  life  without  giving  her  the  satisfaction  of  a  child.  Such  patients 
should  be  protected  against  the  inevitable  damage  of  repeated  attempts 
at  pregnancy,  as  well  as  against  the  present  one,  and  this  can  be  ac- 
complished by  a  single  operation,  unless  the  patient's  condition  is  such 
that  laparotomy  is  considered  too  dangerous. 

To  summarize  l)riefly :  whenever  the  patient's  condition  is  such  that 


84  CESAREAN  SECTION 

abortion  is  urgently  called  for  and  the  attendant  feels  that  the  indication 
against  pregnancy  is  a  permanent  one,  the  desired  result  is  best  accom- 
plished by  termination  of  the  pregnancy,  and  sterilization  at  a  single 
operation,  unless  the  patient's  condition  is  so  precarious  that  it  is  felt 
that  termination  of  the  pregnancy  is  all  that  should  be  attempted,  and 
that  the  question  of  sterilization  should  be  left  for  the  future  in  case 
she  reacts  favorably  to  the  abortion. 


LITEEATURE 

BoLDT,  H.  S.  Caesarean  Section  on  a  Child  Twelve  Years  and  Eight 
Months  Old,  with  Contracted  Pelvis,  for  Severe  Puerperal 
Eclampsia.     Post-Grad.     Dec,  1905. 

DoKTOR.    Kaiserschnitt  bei  Sepsis.    Arch.  f.  Gyn.    1899.    59:200. 

Halbertsma.  Eclampsia  Gravidarum  eine  Neue  Tndicationsstellung 
fiir  die  Sectio  Caesarea.    Centrbl.  f.  Gyn.     1889.     13:  901. 

McPherson,  R.  Treatment  of  Placenta  Previa  by  Cesarean  Section. 
Am.  Jr.  Obst.    4 :  68. 

Reynolds.  Circumstances  which  Render  the  Elective  Section  Justifi- 
able In  the  Interest  of  the  Child  Alone.  Am.  Med.  1901.  2: 
480. 

ScHACHNER,  A.  Cesarean  Section  for  Eclampsia  in  Twin  Pregnancy. 
N.  Y.  Med.  Rec.     Dec.  i,  191 7. 

Whitall,  J.  D.  An  Unusual  Indication  for  Caesarean  Section,  Ven- 
trosuspension  of  the  Uterus.    N.  Y.  Med.  Jr.    Jan.  4,  191 3. 


CHAPTER  VI 

CONTRA-INDICATIONS   TO   THE   ELECTIVE   CESAREAN    SECTION 

Definition  of  Elective  Cesarean  Section — The  Absolute  Indication — The  Elective 
Operation  vs.  Operation  at  the  Time  of  Election — Best  Time  for  Operation — 
Fundamental  Principles  Governing  the  Operation — Conditions  Increasing  Danger 
to  Maternal  Life — Infection — Exhaustion — Attempts  at  Pelvic  Delivery — Infec- 
tious Diseases — Surrounding  Conditions — Training  of  the  Attendant  in  Relation 
to   Choice  of   Operation — Bibliography. 

By  the  term  "elective  cesarean  section"  we  mean  the  performance  of 
cesarean  section  to  accomplish  delivery  when  the  conditions  present  in 
the  given  case  are  such  that,  although  it  is  possible  to  deliver  the  patient 
per  vaginam,  cesarean  section  is  selected  as  the  preferable  operation  for 
the  individual  patient. 

In  cases  of  pelvic  contraction  so  extreme  that  the  extraction  of  the 
child  cannot  be  accomplished,  even  after  craniotomy,  or  when  the  pelvis 
is  so  obstructed  by  tumors  that  delivery  per  vaginam  is  impossible,  the 
indication  for  abdominal  delivery  is  absolute,  but  in  most  other  conditions 
the  obstetrician  has  at  his  command  various  methods  by  which  delivery 
is  possible,  and  the  abdominal  delivery  becomes  an  elective  procedure. 
Some  operators  go  so  far  as  to  say  that,  if  the  choice  of  any  other 
operative  procedure  involves  the  destruction  of  a  living  child,  the  in- 
dication for  cesarean  section  becomes  absolute,  no  matter  what  risks  it 
may  involve  for  the  mother,  but,  in  my  opinion,  cesarean  section  is 
under  certain  circumstances  too  dangerous  an  operation  for  the  mother 
to  be  undertaken,  and  I  believe  that  the  destruction  of  a  living  child  is 
still  justifiable  in  certain  cases  of  neglected  labor,  and  is  preferable  to 
cesarean  section  followed  by  hysterectomy,  unless  the  risks  of  the  pelvic 
operation  are  considered  practically  equal  to  those  of  the  abdominal 
delivery. 

In  using  the  term  "elective  cesarean  section"  care  must  be  taken  not 
to  confuse  it  with  "cesarean  section  at  the  time  of  election."  By  the 
latter  term  we  mean  the  performance  of  cesarean  section,  the  ad- 
visability of  which  has  been  already  determined,  at  the  time  when  better 
results  for  the  mother  and  equally  good  results  for  the  child  are  to  be 
expected  than  if  the  operation  is  per-formed  at  any  other  time.     It  is  to- 

85 


86  CESAREAN  SECTION 

day  very  generally  agreed  that,  if  the  operation  be  performed  shortly 
before  the  estimated  onset  of  labor,  or  within  a  few  hours  after  labor  has 
begun,  the  interests  of  both  patients  are  served  to  the  highest  degree, 
and  that  the  results  of  operation  at  this  time  will  be  more  nearly  ideal 
than  at  any  other  time.  The  definition  of  elective  cesarean  section  has 
already  been  given. 

Certain  fundamental  principles  underlie  the  success  or  failure  of 
any  surgical  procedure,  and  although  under  certain  circumstances  there 
may  be  no  alternative  but  to  perform  the  operation  in  violation  of  these 
principles,  the  results  in  general  will  be  such  as  to  prove  the  wisdom  of 
not  departing  too  widely  from  them  when  any  liberty  of  choice  exists. 

From  time  to  time  series  of  cases  are  published  with  the  apparent 
object  of  proving  that  the  principles  which  govern  success  in  cesarean 
section  may  be  disregarded  with  impunity,  at  least  by  certain  surgeons; 
but  in  one  such  instance  it  has  been  my  privilege  to  follow  the  subsequent 
work  of  the  author  of  one  of  these  papers,  and  it  is  sufficient  comment 
to  say  that  he  has  not  published  the  results  of  his  more  recent  opera- 
tions, and  that  those  who  have  followed  his  lead  have  not  published  their 
results  at  all. 

It  must  never  be  forgotten  that  cesarean  section  is  a  major  abdominal 
operation,  and  that  a  disregard  of  the  conditions  which  render  abdominal 
surgery  safe  will  sooner  or  later  bring  its  own  reward.  Although  the 
occasional  operator  may  escape,  for  a  time  at  least,  the  logical  penalty 
of  disregarding  surgical  principles,  the  net  results  of  reckless  operating 
will  show  so  high  a  mortality  as  to  prove  the  danger  of  not  following 
the  rules  which  determine  the  safety  of  any  surgical  procedure. 

At  the  present  time  cesarean  section  is'  recognized  as  an  operation 
of  election  for  the  preservation  of  fetal  life  or  maternal  health.  If 
undertaken  under  proper  conditions  and  in  selected  cases,  it  is  practically 
little,  if  any,  more  dangerous  than  any  other  clean  abdominal  operation. 
If  the  conditions  which  render  abdominal  surgery  in  general  safe  are 
not  fulfilled,  at  least  to  a  great  extent,  cesarean  section  should  not  be 
selected,  unless  it  is  the  case  that  any  other  possible  procedure  carries 
with  it  a  practically  equal  risk  to  the  mother,  in  which  case  the  preserva- 
tion of  the  child  may  properly  prove  the  determining  factor.  Being  an 
operation  for  the  preservation  of  fetal  life,  it  is  seldom  indicated  in 
cases  where  the  child  is  known  or  believed  to  have  perished,  except  when 
no  other  method  of  delivery  is  possible,  unless  the  conditions  present  in 
the  given  case  render  it  the  safest  operation  for  the  mother.  If  the  con- 
ditions present  lead  to  the  conclusion  that,  although  a  living  child  may 
be  obtained,  the  mother's  life  will  probably  be  sacrificed,  cesarean  section 


CONTRA-INDICATIONS  TO  ELECTIVE  CESAREAN  SECTION     87 

becomes  an  unjustifiable  procedure,  since  the  maternal  life  should  always 
be  considered  as  the  more  important,  if  choice  is  possible.  Religious 
scruples  on  the  part  of  the  patient  or  surgeon  may  occasionally  necessi- 
tate the  performance  of  cesarean  section  under  conditions  which  do  not 
give  the  mother  a  fair  chance  for  her  life,  but  in  the  great  majority  of 
cases  it  may  be  fairly  said  that  no  operation  is  permissible  to  save  the 
child  which  is  believed  to  seriously  endanger  the  mother,  when  any 
other  operation  can  be  performed  which  will  increase  the  safety  of  the 
mother,  even  though  it  may  involve  the  loss  of  the  child. 

There  are  certain  conditions  which  enter  largely  into  the  determina- 
tion of  the  degree  of  danger  to  the  mother  in  any  given  case,  and  it  is 
of  the  utmost  importance  that  these  conditions  should  be  recognized  and 
be  given  careful  consideration  in  the  choice  of  operation.  The  great 
majority  of  patients  who  present  indications  for  cesarean  section  can 
be  divided  into  two  distinct  groups,  the  favorable  and  the  unfavorable. 
For  a  patient  to  be  classed  as  favorable  certain  conditions  must  be 
fulfilled  :  (i)  There  must  be  no  suspicion  of  uterine  infection.  (2)  She 
must  not  show  signs  of  exhaustion,  whether  general  or  uterine,  from 
any  labor  which  may  have  occurred.  (3)  There  must  have  been  no 
attempts  at  operative  delivery  from  below.  (4)  There  must  be  no  sign 
of  intercurrent  infectious  disease.  (5)  She  must  be  so  situated  that  it 
is  possible  for  the  operation  to  be  performed  in  a  properly  equipped 
hospital,  or  else  hospital  conditions  must  be  reproduced  in  the  home,  and 
efficient  after  care  must  be  provided  for. 

The  converse  of  any  of  these  conditions  renders  the  patient  at  least 
a  relatively  unfavorable  risk  for  cesarean  section,  and  although,  under 
certain  circumstances,  cesarean  section  may  still  be  elected  as  the  opera- 
tion which  will  on  the  whole  give  the  best  results,  the  outcome  of  the 
operation  is  more  doubtful  than  if  no  unfavorable  conditions  were 
present,  and  the  prognosis  must  be  stated  accordingly.  It  may  be  that 
the  patient  will  prefer  not  to  submit  to  an  operation  which  carries  with 
it  a  considerable  risk  to  her  life  for  the  sake  of  a  living  child,  and  her 
preferences  must  be  given  adequate  consideration,  especially  if  she  has 
other  children,  since  her  life  is  much  more  important  than  the  life  of 
the  child,  and  she  has  a  perfect  right  to  refuse  an  operation  which  carries 
with  it  more  than  ordinary  risks  to  her  life  for  the  sake  of  preserving 
the  child. 

Uterine  Infection. — That  definite  uterine  infection  should  be  an 
absolute  contra-indication  to  cesarean  section,  unless  the  operation  is 
completed  by  removal  of  the  uterus,  is  generally  conceded,  since  the 
retention  of  the  infected  uterus  often  results  in  fatal  peritoneal  infection, 


88  CESAREAN  SECTION 

no  matter  whether  a  classical  or  extraperitoneal  operation  be  performed. 
Some  operators  attempt  to  treat  these  cases  by  the  extraperitoneal  opera- 
tion, but  the  results  are  not  sufficiently  good  to  warrant  the  risk  in 
frankly  infected  cases,  although  in  doubtful  cases  the  operation  may  be 
justifiable.  A  certain  proportion  of  infected  patients  undoubtedly  re- 
cover from  cesarean  section  after  a  stormy  convalescence,  but  the 
mortality  is  so  great  that  the  conservative  operation  is  absolutely  contra- 
indicated  in  the  presence  of  frank  infection,  and  an  abdominal  delivery 
should  never  be  performed  under  these  conditions  when  any  other  method 
of  delivery  is  possible.  If,  however,  cesarean  section  seems  to  be  the 
only  available  method  of  delivery  under  such  circumstances,  supravaginal 
amputation  of  the  uterus  should  always  complete  the  operation,  and  the 
infected  uterus  should  never  be  replaced  in  the  abdomen  to  act  as  a 
source  of  peritoneal  infection. 

Patients  who  have  been  repeatedly  examined  during  labor,  even 
under  strict  asepsis,  are  relatively  poor  risks  for  cesarean  section,  since 
each  examination  increases  the  risk  of  uterine  infection,  and  if  the  asepsis 
has  been  poor  or  doubtful  the  risks  of  the  conservative  cesarean  section 
are  much  increased,  even  though  no  signs  of  infection  are  evident,  since 
it  is  almost  certain  that  infective  organisms  have  been  introduced  into 
the  uterine  cavity  in  such  cases,  and  contamination  of  the  peritoneum  or 
infection  of  the  uterine  wound  is  probable.  In  cases  of  this  nature  an 
extraperitoneal  operation  will  give,  as  a  rule,  better  results,  though  if  it 
is  possible  to  avoid  abdominal  delivery  altogether  and  deliver  the  patient 
by  some  other  method,  this  should  be  done,  unless  the  child  is  in  excellent 
condition  and  cesarean  section  seems  to  offer  the  only  chance  for  its  life. 
Even  then,  unless  the  parents  elect  to  run  the  increased  risk  for  the  sake 
of  preserving  the  life  of  the  child,  with  full  knowledge  that  it  may  mean 
the  life  of  the  mother,  the  operation  is  an  improper  one.  If  the  child 
is  not  in  first  rate  condition,  a  destructive  operation  is  preferable,  unless 
extraction  of  even  a  mutilated  child  is  impossible  on  account  of  pelvic 
obstruction. 

In  the  same  category  should  be  placed  patients  in  whom  the  mem- 
branes have  been  ruptured  for  a  considerable  period.  It  is  a  well  recog- 
nized fact  that  premature  rupture  of  the  membranes  predisposes  markedly 
to  infection  of  the  amniotic  cavity  and  in  some  cases  to  uterine  infection. 
Slemons  has  shown  that  infectious  organisms  not  infrequently  invade 
the  placenta  and  are  transmitted  to  the  fetus,  causing  its  death  by  septi- 
cemia, either  before  or  a  few  days  after  birth.  It  is  evident,  therefore, 
to  what  danger  of  peritoneal  infection  a  patient  is  exposed  when  under 
such  circumstances  she  is  subjected  to  an  abdominal  delivery,  since  it  is 


CONTRA-INDICATIONS  TO  ELECTIVE  CESAREAN  SECTION     89 

very  difficult  to  avoid  infection  of  the  surrounding  tissues  when  the 
uterus  is  opened.  The  wonder  is  not  that  the  results  are  bad,  if  the  mem- 
branes have  been  ruptured  more  than  a  few  hours,  but  that  any  patients 
survive. 

Patients  In  whom  attempts  have  been  made  to  induce  labor  by  means 
of  a  bag  or  bougie,  or  in  whom  serious  attempts  at  pelvic  delivery  have 
been  made  by  operative  means,  are  also  bad  risks  for  cesarean  section. 
No  matter  how  careful  the  aseptic  technic  of  such  procedures  has  been, 
there  is  always  sufficient  risk  of  uterine  contamination  under  these  con- 
ditions to  contra-indicate  a  classical  cesarean  section,  unless  followed  by 
hysterectomy,  and  although  an  extraperitoneal  operation  would  involve 
less  risk,  it  is,  in  my  opinion,  a  doubtful  procedure.  I  personally  prefer 
in  such  cases  to  accomplish  the  delivery  per  vaginam,  if  possible,  even 
though  it  may  involve  a  destructive  operation  on  a  living  child.  The 
proper  time  for  cesarean  section  is  before  the  uterine  cavity  has  been 
infected  by  repeated  manipulations,  and  the  mortality  and  morbidity 
which  attend  cesarean  section  after  attempts  at  pelvic  operative  delivery 
are  such  as  to  contra-indicate  it  when  any  other  method  of  delivery  is 
possible. 

Exhaustion. — The  element  of  exhaustion,  as  a  contra-indication  to 
the  elective  cesarean  section,  should  receive  careful  consideration  in 
every  patient  who  has  been  in  labor  for  any  length  of  time,  since  it  is 
evident  that  an  exhausted  patient  is  a  much  poorer  subject  for  abdominal 
surgery  than  a  patient  in  good  condition,  and  the  mortality  and  morbidity 
will  be  distinctly  higher,  the  greater  the  degree  of  exhaustion  present, 
the  patient's  lowered  resistance  making  even  a  low  grade  infection  serious, 
which  might  cause  little  trouble  if  she  were  in  good  condition. 

Exhaustion  in  its  relation  to  rendering  a  patient  unfit  for  abdominal 
delivery  must  be  considered  from  a  dual  standpoint,  i.e.,  general  exhaus- 
tion from  prolonged  or  excessive  labor,  and  exhaustion  of  the  uterus  as 
evidenced  by  increasing  rigidity  or  by  irregularity  of  the  previously 
regular  contractions. 

That  general  physical  exhaustion  renders  the  prognosis  of  abdominal 
surgery  worse  needs  little  comment,  since  it  is  evident  that  the  lower  the 
patient's  vitality  the  poorer  her  chance  of  standing  a  major  operation 
well,  and  cesarean  section  should  always  be  avoided  when  any  other 
means  of  delivery  is  possible  in  these  cases.  This  is  particularly  the 
case  since  the  vitality  of  the  child  will  have  suffered  to  a  considerable 
degree,  and  serious  risks  should  not  be  taken  for  the  mother  for  the 
sake  of  a  child  whose  chances  of  survival  are  doubtful. 

Exhaustion  of  the  uterus  should  also  be  considered  as  markedly  in- 


90  CESAREAN  SECTION 

creasing  the  risks  of  abdominal  delivery,  and  although  in  patients  who 
have  developed  signs  of  uterine  exhaustion  resulting  in  rigidity  of  the 
uterus,  a  thinning  out  of  the  lower  segment,  and  a  rising  contraction  ring, 
cesarean  section  may  seem  to  be  indicated  as  the  most  conservative  pro- 
cedure under  the  circumstances,  owing  to  the  imminent  danger  of  uterine 
rupture,  if  operation  is  attempted  from  below,  the  operation  will  have  a 
relatively  high  mortality  and  morbidity.  Hysterectomy  in  these  cases 
will  improve  the  patient's  chances  materially,  although  the  substitution 
of  an  extraperitoneal  operation  for  the  classical  one  is  justifiable,  unless 
the  patient  is  believed  to  have  been  already  infected  and  will  give  greatly 
improved  results. 

Intercurrent  Diseases. — It  may  be  laid  down  as  a  general  principle 
that  acute  infectious  diseases  render  the  prognosis  of  cesarean  section  so 
doubtful  as  to  contra-indicate  its  performance  as  an  elective  procedure. 
The  danger  of  infection  of  the  uterine  wound,  with  the  subsequent  in- 
fection of  the  peritoneal  cavity,  is  so  much  increased  in  these  cases  that 
operation  should  be  avoided  whenever  possible. 

The  toxemias  of  pregnancy  have  already  been  discussed  as  indications 
for  the  operation,  but  it  may  be  well  to  consider  them  briefly  from  the 
opposite  standpoint.  Preeclamptic  toxemia  is  a  condition  of  lowered 
vitality  with  diminished  excretions.  Furthermore  there  is  a  certain 
amount  of  evidence  that  one  of  the  factors  in  the  production  of  toxemia 
may  be  concealed  sepsis,  and  blood  cultures  in  toxemic  women  are  re- 
ported to  show  a  positive  growth  in  a  considerable  proportion  of  cases. 
We  have  then  in  these  cases  two  factors  which  increase  the  dangers  of 
abdominal  operations,  auto-intoxication  and  possibly  septicemia. 

The  two  most  important  objects  sought  in  the  treatment  of  toxemia 
are:  first,  the  removal  of  the  ultimate  cause  of  the  disease — the  child — 
and  thus  the  prevention  of  the  further  absorption  of  toxins ;  and  second 
the  removal  of  the  toxins  which  produce  the  symptoms.  The  major 
portion  of  the  toxins  is  presumably  excreted  through  the  intestinal  tract, 
and  it  is  well  known  that  it  is  often  very  diflicult  to  secure  free  catharsis 
for  several  days  after  cesarean  section.  It  is  evident,  therefore,  that  if 
the  patient  has  retained  in  her  blood  any  considerable  amount  of  a 
virulent  toxin,  the  excretion  of  which  is  interfered  with  by  the  intestinal 
paresis  following  an  abdominal  operation,  the  prognosis  of  the  operation 
will  be  worse  than  in  a  normal  patient,  and  also  that  the  danger  from 
the  toxemia  may  be  increased  to  some  extent,  owing  to  lack  of  prompt 
elimination  of  the  toxins.  These  dangers  may  not  nullify  the  other 
advantages  of  cesarean  section  in  the  given  patient,  but  they  alter  the 
prognosis  for  the  worse,  and  cesarean  section  should  not  be  selected  as 


CONTRA-INDICATIONS  TO  ELECTIVE  CESAREAN  SECTIOxN     91 

the  routine  method  of  dehvery  for  every  toxemic  or  eclamptic  patient, 
but  only  when  careful  examination  of  the  patient  shows  that  other 
methods  of  delivery  possess  even  greater  disadvantages  and  section  is, 
on  the  whole,  the  less  dangerous  method. 

Chronic  nephritis  or  other  chronic  diseases  must  also  be  considered 
as  altering  the  prognosis  of  cesarean  section  somewhat  for  the  worse, 
but  if  any  valid  reason  exists  for  the  performance  of  abdominal  delivery 
in  these  cases,  it  should  be  performed  without  hesitation,  although  the 
results  will  show  a  somewhat  increased  mortality  and  morbidity  over 
what  is  to  be  expected  in  women  in  a  normal  condition  of  health. 

Acute  nephritis  from  any  cause  will  alter  the  outlook  materially  for 
the  worse,  and  although  in  toxemia  and  other  conditions  which  produce 
acute  nephritis  the  operation  may  be  indicated,  the  results  will  not  be  as 
satisfactory  as  in  normal  women,  and  abdominal  delivery  should  be 
avoided,  if  possible. 

In  other  words  any  condition  which  results  in  lowered  vitality  and 
resistance  on  the  part  of  the  patient  ofi'ers  a  relative  contra-indication  to 
cesarean  section,  and  its  performance,  under  such  conditions,  is  only 
justifiable  when  the  advantages  to  be  gained  more  than  compensate  for 
the  increased  risk. 

Surrounding  Conditions. — There  can  be  no  doubt  but  that  the  cir- 
cumstances under  which  the  patient  is  placed  and  the  surgical  skill  at 
her  command,  as  well  as  the  means  for  proper  after  care,  should  have  a 
serious  influence  on  the  choice  of  operation. 

The  conditions  which  appertain  to  a  first  class  surgical  hospital,  com- 
bined with  first  class  surgical  skill  on  the  part  of  the  attendant,  will  do 
most  to  ensure  a  successful  result,  and  the  more  nearly  the  circumstances 
of  the  patient  can  approximate  these,  the  better  the  prognosis.  A  good 
result  may  ordinarily  be  predicted,  however,  if  the  patient's  surroundings 
are  such  that  the  ordinary  aseptic  precautions  can  be  observed  during 
the  operation  and  efficient  after  care  provided  for  during  the  convales- 
cence. Unless  these  conditions  can  be  fulfilled,  the  patient  will  have  a 
better  chance  of  recovery  after  a  difficult  pelvic  delivery  than  after  a 
laparotomy,  and  this  fact  should  receive  due  consideration  in  the  choice 
of  operation,  even  though  it  is  recognized  in  advance  that  a  pelvic  de- 
livery will  probably  involve  the  loss  of  the  child. 

Cesarean  section  has  been  performed  successfully  in  a  farmhouse  by 
candle  light  and  without  trained  assistants,  but  a  single  successful  case 
does  not  warrant  our  choosing  improper  surroundings  for  our  patients 
when  more  or  less  ideal  conditions  can  be  obtained.  Serious  surgery 
under  improper  conditions  is  sure  to  be  attended  by  a  much  higher 


92  CESAREAN  SECTION 

mortality  than  if  good  hospital  conditions  can  be  provided,  and  a  room 
in  a  tenement  house  is  not  a  satisfactory  operating  room.  If,  therefore, 
hospital  facilities  are  not  obtainable,  or  to  be  reproduced  in  the  patient's 
home,  cesarean  section  should  not  be  elected,  if  any  other  operation  can 
be  done  with  due  regard  to  the  safety  of  the  mother. 

Efficient  after  care  is  necessary  after  any  abdominal  operation,  to 
ensure  first,  the  safety  of  the  patient,  and  second,  her  comfort.  Trained 
nurses  are  obtainable  at  the  present  time  in  most  communities,  even 
where  there  are  no  hospital  facilities,  but  if  it  is  not  possible  to  provide 
for  proper  after  care,  cesarean  section  should  not  be  performed  when 
any  other  operation  is  possible. 

The  surgical  skill  at  the  command  of  the  patient  is  another  factor 
which  must  enter  into  the  choice  of  operation.  If  the  attendant  has  had 
no  surgical  training  and  no  trained  surgeon  can  be  procured,  cesarean 
section  should  only  be  considered  as  an  operation  of  last  resort.  Although 
a  classical  cesarean  section  is  not  an  operation  of  great  technical  difficulty, 
and  in  fact  is  much  easier  than  any  but  the  simplest  obstetrical  pro- 
cedures, safety  in  its  performance  demands  a  thorough  knowledge  of 
asepsis,  which  the  average  physician  not  trained  in  surgery  does  not 
possess.  Any  failure  in  asepsis  in  abdominal  surgery  is  liable  to  prove 
much  more  serious  than  in  pelvic  operating,  since  the  patient  whose 
peritoneum  is  infected  has  little  or  no  chance  to  overcome  the  infection, 
whereas  the  patient  with  puerperal  infection  will,  in  the  great  majority 
of  cases,  recover,  if  properly  treated.  On  the  other  hand,  it  must  be  re- 
membered that,  although  the  conservative  cesarean  section  is  a  simple 
procedure,  it  may  be  necessary  in  any  case  to  remove  the  uterus  for  un- 
controllable hemorrhage  or  on  account  of  previous  infection,  an  operation 
which  requires  a  surgical  training  for  its  proper  performance.  It  is  fair 
to  say,  therefore,  that  cesarean  section  is  an  operation  which  should  not 
be  undertaken  by  any  operator,  unless  his  training  is  such  as  to  enable 
him  to  carry  the  operation  to  its  logical  conclusion,  no  matter  what 
complications  may  arise. 

If  the  attendant  or  consultant  happens  to  be  a  trained  abdominal 
operator  and  yet  has  had  no  proper  training  in  obstetric  operating,  it  is 
conceivable  that  conditions  may  arise  which  will  warrant  his  performing 
a  cesarean  section  under  circumstances  in  which  a  pelvic  operation  would 
ordinarily  be  indicated  for  a  properly  trained  obstetrician,  since  his 
special  training  has  fitted  him  to  perform  one  operation,  but  not  the 
other,  and  the  patient's  chances  will  be  better  if  he  does  the  operation  he 
is  qualified  to  perform,  other  things  being  equal,  rather  than  if  he  at- 
tempts an  operation  with  the  technic  of  which  he  is  unfamiliar.     How- 


CONTRA-INDICATIONS  TO  ELECTIVE  CESAREAN  SECTION     93 

ever,  unless  the  case  is  an  emergency  one  and  the  time  necessary  to 
summon  a  properly  trained  obstetric  consultant  may  mean  the  life  or 
death  of  the  patient,  he  is  not  justified  in  operating,  since  it  is  probable 
that  his  judgment  as  to  the  needs  of  the  patient  will  prove  just  as  faulty 
as  his  ignorance  of  obstetric  operating  is  profound,  and  he  will  probably 
perform  an  operation  which  not  only  is  unnecessary  under  the  circum- 
stances, but  which  also  exposes  the  patient  to  a  much  greater  risk  than 
is  proper,  simply  l^ecause  in  his  ignorance  of  obstetrics  he  is  not  qualified 
to  effect  delivery,  except  by  the  abdominal  route. 

There  is  no  question  but  that  many  cesarean  sections  are  performed 
every  year  simply  because  the  consultant  called  to  the  case  has  no 
knowledge  of  obstetric  diagnosis  and  technic.  He  sees  a  patient  whom 
the  family  physician  has  failed  to  deliver,  and,  without  the  proper 
knowledge  to  determine  what  the  patient  really  needs,  he  empties  the 
uterus  by  the  abdominal  route  as  the  easiest  method.  His  surgical  con- 
science would  probably  not  allow  him  to  perform  an  ordinary  operation 
with  so  little  appreciation  of  the  needs  of  the  patient,  and  women  in 
labor  should  not  be  exposed  to  such  unscrupulous  methods.  There  is 
no  doubt  but  that  many  women  are  sacrificed  every  year  to  the  lack  of 
professional  conscience  which  permits  a  surgeon  to  determine  the  fate  of 
a  patient  as  to  whose  needs  he  is  in  absolute  ignorance,  except  that  it  is 
probably  necessary  to  deliver  her  by  some  means,  and  even  then  an 
immediate  delivery  may  not  be  indicated  under  the  conditions  present  in 
the  given  case. 

LITEEATUEE 

Ehrenfest.  The  Impropriety  of  Caesarean  Section  in  Placenta 
Praevia.     Am.  Med.     1902.    3 :  64. 

Holmes.  Caesarean  Section  for  Placenta  Praevia  an  Improper  Pro- 
cedure.   Jr.  Am.  Med.  Assn.     1905.    44:1594. 

Jellett.  The  Place  of  Caesarean  Section  in  the  Treatment  of  Pla- 
centa Praevia.    Lancet,  1910.    j. :  1271. 

Murray,  R.  A.  The  Limitations  of  Cesarean  Section.  Am.  Jr.  Obst. 
1893.     27. 

Williams.     The  Abuse  of  Cesarean  Section.     Surg.  Gyn.  Obst.     191 7. 


CHAPTER  VII 

PREPARATIONS  FOR  OPERATION 

Time  of  Operation^Necessity  for  Prenatal  Study — Advantages  of  Operation  at  a 
Fixed  Date — Operation  Before  Completion  of  Pregnancy — Heart  Conditions — 
Toxemia — Hemorrhage — Precautions,  if  Test  of  Labor  is  Given — Preparation  of 
Patient  for  Operation — Fixed  Date — Emergency — Preparation  of  Field  of  Opera- 
tion— The  Operator  and  Assistants — Instruments  and  Sutures — Dressings — 
Choice  of  Anesthetic ;  General ;  Spinal ;  Local. 

Time  of  Operation. — Unfortunately,  owing  to  a  lack  of  adequate 
obstetric  training  on  the  part  of  the  general  practitioner,  who  is  seldom 
able  to  properly  measure  the  pelvis,  and  to  the  fact  that  the  great  majority 
of  pregnant  women  are  not  under  careful  supervision  during  pregnancy, 
a  large  proportion  of  the  cases  which  come  to  cesarean  section  are  not 
recognized  as  offering  indications  for  the  operation,  until  a  more  or 
less  prolonged  test  of  labor  has  demonstrated  the  need  for  operative 
interference.  In  many  cases  the  failure  of  the  ordinary  obstetric  opera- 
tions to  accomplish  delivery,  or  the  occurrence  of  severe  hemorrhage  or 
convulsions,  affords  the  first  evidence  that  the  patient  presents  a  condi- 
tion which  calls  for  radical  treatment,  and  up  to  that  time  both  patient 
and  physician  have  been  trusting  that,  since  parturition  should  be  a  nor- 
mal physiological  process,  nature  may  be  expected  to  look  out  for  the 
interests  of  the  patient.  That  such  a  condition  of  affairs  is  possible  is  a 
reproach  to  obstetric  teaching,  in  that  it  proves  that  the  great  majority 
of  physicians  have  not  been  taught  to  care  for  obstetric  cases  properly, 
since  they  do  not  recognize  the  importance  of  prenatal  examination,  and 
attempt  to  conduct  labor  on  the  time  honored  theory  that  pregnancy  and 
labor  will  progress  normally  and  the  attendant  is  not  responsible  for 
any  untoward  results  which  may  occur.  The  traditions  of  obstetrics 
teach  that  every  woman  may  be  expected  to  deliver  herself  or  be  de- 
livered by  an  operation  of  not  undue  difficulty,  and  that  if  she  does  not 
and  cannot,  owing  to  the  conditions  present  in  her  case,  she  alone  is  to 
blame.  It  is  only  within  comparatively  recent  years  that  the  responsibility 
of  the  physician  for  the  welfare  of  his  patient  has  been  recognized  and 
that  it  is  the  obstetrician's  duty  to  safeguard  his  patient  by  every  means 

94 


PREPARATIONS  FOR  OPERATION  95 

known  to  modern  science.  If  he  is  unable  to  determine  himself  whether 
his  patient  requires  more  care  and  skill  than  he  is  qualified  to  give  her, 
he  should  refer  her  to  an  expert  for  an  opinion  before  trouble  arises  and 
not  be  satisfied  to  call  for  help  when  in  many  cases  it  is  too  late. 

Modern  obstetric  teaching  must  include  a  course  in  prenatal  care  and 
careful  instruction  in  pelvimetry  and  in  the  estimation  of  probable  dis- 
proportion between  the  child  and  the  maternal  pelvis,  and  every  student 
who  receives  a  medical  degree  in  the  future  should  be  carefully  instructed 
that  no  woman  should  be  considered  as  normal  for  childbearing  until  a 
painstaking  examination  has  proved  her  to  be  so.  If  intelligent  prenatal 
examination  is  conducted  on  these  lines,  the  great  majority  of  obstetric 
abnormalities  will  be  discovered  before  the  patient  goes  into  labor,  and 
if  cesarean  section  is  necessary  or  advisable,  that  fact  will  be  discovered 
before  labor  begins,  and  in  doubtful  cases  the  patient  can  be  referred  to 
a  specialist  for  an  opinion. 

Statistics  show  that  the  results  of  cesarean  section  are  best,  if  the 
operation  is  performed  at  an  appointed  date  a  few  days  before  the 
estimated  date  of  labor,  or  within  a  few  hours  of  its  onset,  before  the 
muscular  efforts  of  labor  have  been  sufficient  to  lower  the  vitality  of 
the  patient  and  before  repeated  vaginal  examination  has  given  rise  to 
uterine  infection.  The  selected  date  will  vary  somewhat  with  the  indica- 
tions for  the  operation,  but  the  most  nearly  ideal  results  will  be  obtained, 
both  for  mother  and  child,  if  this  rule  is  adhered  to.  At  this  time  the 
mother  will  be  in  the  best  possible  condition  for  operation,  the  increasing 
irritability  of  the  uterus  as  the  end  of  pregnancy  is  approached  will 
ensure  the  proper  contraction  and  retraction  necessary  for  the  control 
of  hemorrhage  at  the  time  of  operation,  and  the  child  will  be  fully  de- 
veloped and  should  survive,  unless  some  congenital  deformity  is  present. 
The  size  of  the  child  should  be  carefully  estimated,  to  avoid  a  possibility 
of  prematurity,  and  if  it  seems  unduly  small,  the  date  of  operation  should 
be  deferred,  in  order  not  to  run  any  risks  for  it. 

Operation  before  the  onset  of  labor  gives  an  opportunity  for  careful 
preparation  of  the  patient  for  operation,  and  the  comfort  of  the  patient 
during  the  early  days  of  the  convalescence  will  be  much  increased,  even 
though  the  end  results  of  the  operation  may  be  equally  successful.  The 
writers  who  advocate  waiting  for  labor  to  begin  in  all  cases  lose  sight  of 
the  fact  that  the  obstetrician  may  possibly  be  engaged  elsewhere  at  the 
time  when  his  patient  goes  into  labor  and  may  not  be  able  to  come  to 
her  for  several  hours,  which  may  entail  much  suffering  on  her  part  as 
well  as  an  alteration  of  the  prognosis  of  the  operation  for  the  worse, 
both  as  regards  mortality  and  morbidity,  a  fact  which  more  than  counter- 


96  CESAREAN  SECTION 

balances  any  theoretical  advantages  of  operating  after  the  onset  of  labor. 

Experience  has  shown  that  the  best  results  are  obtained  by  operation 
at  the  time  of  election,  either  before  labor  begins  or  very  shortly  after. 
From  this  time  on  every  hour  of  active  labor  alters  the  prognosis  some- 
what for  the  worse,  both  as  regards  mortality  and  morbidity,  both  of 
which  are  increased  if  the  patient  is  examined  vaginally  at  frequent 
intervals  to  watch  the  progress  of  the  labor,  or  if  the  membranes  have 
been  ruptured  for  any  considerable  length  of  time  before  the  performance 
of  the  operation. 

In  late  cases,  i.e.,  those  who  have  been  in  active  labor  for  a  long  time, 
on  whom  many  vaginal  examinations  have  been  performed,  even  under 
adequate  aseptic  precautions,  or  in  whom  serious  attempts  at  pelvic 
delivery  have  been  made,  the  prognosis  both  for  mortality  and  morbidity 
is  such  that  cesarean  section  should  only  be  undertaken  when  the  child 
is  in  good  condition,  and  no  other  method  of  delivery  of  a  living  child 
is  possible,  and  when  the  facts  have  been  put  squarely  before  the  patient 
and  her  husband,  so  that  they  may  understand  the  dangers  of  an  abdomi- 
nal delivery  under  the  conditions  and  have  an  opportunity  to  choose 
whether  the  risks  shall  be  taken  or  not,  according  to  the  value  placed  on 
the  child. 

Under  certain  circumstances  an  earlier  date  than  the  normal  time  of 
election  may  be  chosen  for  definite  reasons,  owing  to  the  desire  to  avoid 
certain  dangers  which  may  arise  either  for  mother  or  child. 

In  certain  heart  conditions  where  the  margin  of  safety  for  the 
patient  is  slight,  on  account  of  threatened  decompensation  or  because  of 
previous  attacks  of  decompensation,  it  may  seem  wiser  to  save  the  diseased 
heart  from  the  strain  of  the  last  two  weeks  of  pregnancy  by  an  early 
operation.  If  abdominal  palpation  shows  that  the  child  is  not  undersized, 
so  that  its  interests  will  not  be  sacrificed  by  the  earlier  delivery,  the  date 
of  operation  may  properly  be  advanced  in  the  interests  of  the  mother, 
and  if  the  mother's  condition  is  seriously  threatening,  the  operation 
may  be  necessary,  even  though  the  child  is  apparently  premature  and 
delivery  entails  considerable  risk  for  it,  since  otherwise  both  patients  may 
be  lost. 

In  severe  toxemia,  occurring  in  the  last  month  of  pregnancy,  when 
for  other  reasons  cesarean  section  is  desirable,  the  date  may  also  be 
advanced  rather  than  to  subject  both  mother  and  child  to  the  dangers  of 
an  increasing  toxemia  which  is  either  severely  threatening  or  has  failed 
to  yield  to  treatment.  In  fact,  the  danger  to  the  child  from  the  maternal 
toxemia  is  so  great  in  these  cases  that  moderate  prematurity  is  distinctly 
less  dangerous  to  its  interests  than  prolongation  of  pregnancy  in  the  face 


PREPARATIONS  FOR  OPERATION  97 

of  a  toxemia  which  does  not  prove  amenable  to  treatment.  The  same 
rule  should  be  applied  to  patients  suffering  from  chronic  nephritis  who 
have  had  repeated  still  births,  the  child  dying  in  the  last  few  weeks  of 
pregnancy,  or  in  cases  of  habitual  death  of  the  fetus  without  demon- 
strable cause. 

In  the  treatment  of  other  obstetric  emergencies,  such  as  severe  hemor- 
rhage, a  similar  course  should  be  adopted  when  the  patient  is  in  the  last 
month  of  pregnancy  and  cesarean  section  is  indicated  by  the  accompany- 
ing conditions.  Cesarean  section  should  seldom  be  performed  in  patients 
who  are  more  than  four  weeks  from  the  estimated  date  of  labor,  except  in 
the  presence  of  absolute  obstruction  of  the  pelvis  or  in  cases  in  which 
it  is  decided  to  end  the  pregnancy  and  sterilize  the  patient  at  the  same 
time.  The  fact  that  in  these  cases  the  baby's  hold  on  life  is  precarious, 
owing  to  its  prematurity,  renders  it  undesirable  to  subject  the  mother 
to  an  abdominal  operation  for  delivery,  unless  very  definite  advantages 
will  result  for  her  from  such  a  course,  and  in  most  cases  some  other 
method  of  delivery  is  both  possible  and  safer  for  her. 

When  labor  has  already  begun  before  the  necessity  for  cesarean  sec- 
tion is  recognized,  or  when  in  doubtful  cases  a  longer  or  shorter  test  of 
labor  is  decided  to  be  advisable,  the  operation  should  be  performed  as 
soon  as  the  indication  is  recognized  as  positive.  Vaginal  examination 
should  be  avoided  in  these  cases  and  rectal  examination  substituted,  and 
the  operation  is  practically  never  indicated  after  serious  attempts  at 
delivery  from  below  have  been  made.  It  must  be  remembered  that  every 
hour  of  active  labor  renders  the  prognosis  more  serious,  and,  therefore, 
no  delay  should  be  permitted  after  the  need  of  the  operation  is  recog- 
nized. In  these  late  operations  the  convalescence  may  be  expected  to  be 
somewhat  more  uncomfortable  on  the  average  than  when  there  has 
been  a  proper  opportunity  to  prepare  the  patient  for  operation,  as  is 
afforded  by  operating  at  a  fixed  date. 

Preparation  of  the  Patient  for  Operation. — When  the  date  of 
operation  is  fixed  the  preparation  of  the  patient  should  begin  approxi- 
mately a  week  in  advance.  The  patient  should  be  advised  to  drink  as  much 
water  as  she  can  force  herself  to  imbibe  without  suffering  actual  dis- 
comfort. The  normal  six  to  eight  glasses  taken  throughout  pregnancy 
should  l3e  increased  to  twelve  to  sixteen,  if  possible.  This  will  result 
in  flushing  out  the  system  thoroughly,  and  in  addition  the  tissues  will 
be  full  of  water,  and  I  believe  that  patients  so  treated  will  suffer  less 
from  thirst  after  operation  than  if  this  routine  is  not  carried  out.  The 
diet  during  this  period  should  be  so  regulated  that  as  little  waste  may  be 
left  in  the  intestinal  tract  as  possible  at  the  time  of  operation,  and  yet 


98  CESAREAN  SECTION 

the  nutrition  maintained  at  a  high  level.  During  the  last  twenty-four 
hours  before  operation  the  diet  should,  be  light  and  easily  digestible, 
foods  which  tend  to  gas  formation  being  avoided. 

The  bowels  should  be  kept  freely  open  during  this  period,  though 
active  catharsis  should  be  avoided,  on  the  theory  that  it  predisposes  to 
intestinal  discomfort  afterwards.  On  the  evening  before  operation  the 
lower  bowel  should  be  cleansed  by  an  ordinary  soap  suds  enema,  which 
should  be  repeated  in  the  morning,  about  two  hours  before  the  time  set 
for  operation.  Severe  catharsis  the  night  preceding  operation  is  to  be 
avoided.  In  the  first  place  it  accomplishes  no  useful  purpose,  if  the 
bowels  have  been  previously  kept  normally  active,  and  by  depriving  the 
patient  of  sleep  often  brings  her  to  operation  in  a  more  or  less  exhausted 
condition  with  a  somewhat  lowered  vitality.  Furthermore,  some  surgeons 
believe  that  catharsis  just  before  operation  increases  the  tendency  to  post- 
operative vomiting.  If  a  cathartic  is  given  the  night  before  operation, 
let  it  be  a  mild  one.  Castor  oil,  which  is  very  commonly  used  as  a  cathar- 
tic in  the  preparation  of  patients  for  laparotomy,  is  to  be  avoided  in 
these  cases,  on  account  of  the  very  definite  tendency  to  initiate  labor 
and  thus  render  an  operation  necessary  in  the  middle  of  the  night,  which 
could  be  performed  to  better  advantage  in  the  morning. 

It  is  a  good  plan  to  give  the  patient  a  mild  hypnotic  the  evening  before 
operation,  to  ensure  a  good  night's  rest  and  to  prevent  her  from  lying 
awake  worrying  about  the  ordeal  of  the  morrow. 

Preparation  of  the  Field  of  Operation. — The  preparation  of  the 
field  of  operation  varies  with  the  personal  preferences  of  the  operator. 
Personally,  when  preparing  a  patient  for  operation  at  a  fixed  date,  I 
prefer  to  begin  the  preparation  the  night  before.  The  patient  is  given 
a  full  bath,  preferably  a  shower  bath,  if  possible.  The  abdomen,  pubic 
region  and  vulva  are  then  shaved  and  scrubbed  with  soap  and  water 
for  five  minutes.  The  soap  is  washed  off  with  sterile  water  and  the 
abdomen  scrubbed  with  70  per  cent  alcohol  for  three  minutes.  A  sterile 
dressing  is  then  applied  and  left  in  place  until  one  hour  before  opera- 
tion, when  it  is  removed  and  the  abdomen  is  painted  with  half  strength 
tincture  of  iodin,  and  another  dressing  applied.  After  the  patient  is 
anesthetized  for  operation  the  dressing  is  finally  removed  and  the  abdomen 
painted  once  more  with  half  strength  iodin.  The  field  of  operation  is 
now  surrounded  by  sterile  sheets  and  towels,  leaving  only  the  necessary 
space  exposed,  and  as  a  final  step  the  iodin  is  washed  off  with  70  per 
cent  alcohol.  This  precaution  is  taken  to  prevent  the  entrance  of 
iodin  into  the  peritoneal  cavity,  on  the  theory  that  the  irritation  it  causes 


PREPARATIONS  FOR  OPERATION  99 

is  liable  to  increase  intestinal  distention  after  operation  and  to  predispose 
to  the  formation  of  adhesions. 

One  half  hour  before  the  patient  is  taken  to  the  etherizing  room 
she  is  given  1/120  of  atropin  subcutaneously,  in  order  to  make  the  work 
of  the  anesthetist  more  easy,  I  have  discarded  the  preoperative  use  of 
morphia  for  two  reasons :  in  the  first  place,  unless  the  patient's  exact 
dose  of  morphia  is  known,  she  is  apt  to  receive  a  slight  over  dose  which 
may  affect  her  respiration  to  some  extent,  making  it  so  shallow  that  it 
may  prove  very  difficult  to  produce  satisfactory  anesthesia ;  and  second, 
because  the  action  of  morphia  given  shortly  before  delivery  is  supposed 
to  render  the  baby  apneic  and  interfere  with  its  resuscitation.  I  am  free 
to  say  that  my  personal  experience  does  not  bear  out  the  latter  theory, 
but  the  interference  with  the  respiration  of  the  mother  may  prove  a  very 
real  disadvantage. 

On  awaking  in  the  morning  the  patient  is  given  an  ether  breakfast, 
consisting  of  a  cup  of  black  coffee  or  bouillon  to  prevent  faintness,  but 
nothing  is  given  by  mouth  within  two  hours  of  the  time  of  operation. 
The  lower  bowel  is  again  emptied  by  a  suds  enema  one  hour  before  the 
time  set  for  operation.  Just  before  being  placed  on  the  etherizing  table 
the  patient  empties  her  bladder  spontaneously  or  is  catheterized,  the 
latter  being  preferable  since  -it  ensures  complete  emptying  of  the  bladder 
and  thus  avoids  the  embarrassment  to  the  operation  which  may  be  caused 
by  a  partly  distended  bladder,  if  a  low  incision  is  used. 

When  the  operation  is  an  emergency  one  on  a  patient  in  labor,  the 
preparation  is  much  more  simple,  but,  as  far  as  I  can  see,  the  results  are 
equally  good.  An  enema  is  given,  unless  the  bowels  have  been  thoroughly 
evacuated  at  the  beginning  of  labor.  The  abdomen  and  pubic  region  are 
given  a  dry  shave  so  as  not  to  interfere  with  the  penetration  of  the  iodin, 
which  is  used  to  prepare  the  field  of  operation.  The  atropin  is  given 
and  the  bladder  emptied,  as  in  the  ordinary  preparation.  The  patient 
is  then  anesthetized  and  brought  to  the  operating  room.  The  preparation 
is  completed  by  painting  the  abdomen  with  full  strength  iodin,  which  is 
washed  off  with  70  per  cent  alcohol  after  the  field  of  operation  has  been 
surrounded  with  sterile  towels. 

A  solution  of  10  per  cent  picric  acid  in  alcohol  may  be  substituted 
for  the  iodin  in  both  methods,  and  is  said  to  have  the  advantage  of 
not  causing  irritation  of  the  peritoneum,  if  it  is  introduced  into  the 
abdominal  cavity  during  operation.  I  have  as  yet  no  personal  experience 
with  its  use. 

Operator  and  Assistants. — In  addition  to  the  operator,  three  assist- 
ants are  needed  to  make  the  operation  go  smoothly,  an  anesthetist,  an 


•100  CESAREAN  SECTION 

operative  assistant,  and  a  second  assistant  or  nurse  to  handle  instru- 
ments and  sutures.  In  addition,  a  competent  person  should  be  delegated 
to  receive  and  resuscitate  the  baby,  so  that  the  operator's  attention  will 
not  be  diverted  from  the  operation  by  anxiety  for  the  baby. 

The  operator  and  all  assistants  who  take  part  in  the  operation  should 
wear  caps,  face  masks  and  sterile  gowns,  so  that  all  possible  means  of 
wound  infection  may  be  avoided,  and  after  a  thorough  preparation  of 
the  hands,  should  don  sterilized  rubber  gloves.  The  method  of  hand 
preparation  varies  with  the  preferences  of  the  individual  surgeon,  but 
the  use  of  rubber  gloves  is  obligatory  in  modern  surgery,  and  the  hands 
must  be  carefully  prepared  by  some  method  before  the  gloves  are  put  on, 
since  otherwise  an  accidental  puncture  of  the  gloves  may  result  in  in- 
fection. 

Instruments  and  Sutures. — For  a  conservative  cesarean  section  a 
very  simple  layout  of  instruments  is  all  that  is  necessary,  but  since  in 
any  case  it  may  prove  necessary  to  remove  the  uterus  for  hemorrhage  or 
other  cause,  the  layout  should  include  all  necessary  instruments  for  that 
operation.  The  following  instruments  are  required :  2  scalpels,  2-4  pairs 
of  scissors,  2  pairs  of  dissecting  forceps,  12  short  and  6  long  artery 
forceps,  I  ligature  carrier  or  Cleveland  needle,  abdominal  retractors,  i 
needle  holder,  and  such  needles  as  the  operator  prefers,  both  curved  and 
straight  with  cutting  and  round  points. 

The  suture  material  varies  with  the  preferences  of  the  individual 
surgeon.  In  the  early  days  of  the  cesarean  operation  the  uterus  was 
closed  by  means  of  a  fine  silver  wire  suture,  which  in  time  was  succeeded 
by  silk  and  later  by  linen  thread  sutures.  In  later  years  the  use  of  non- 
absorbable sutures  in  the  uterus  has  largely  been  given  up  for  various 
reasons,  but  particularly  because,  whenever  infection  of  the  uterine 
wound  occurred,  a  long  and  painful  convalescence  ensued,  accompanied 
by  the  discharge  of  suture  material  from  the  wound  over  a  long  period  of 
time.  This  disadvantage  is  not  limited  to  the  immediate  period  of  con- 
valescence, since  in  two  of  my  own  cases  the  wounds  which  had  ap- 
parently healed  properly  broke  down  after  an  interval  of  six  months  in 
one  case  and  a  year  in  the  other,  and  did  not  heal  until  several  sutures  had 
been  discharged.  At  the  present  time  some  form  of  absorbable  material 
is  ordinarily  employed  for  the  buried  sutures,  chromicized  or  iodized 
catgut  or  kangaroo  tendon,  according  to  the  preferences  of  the  operator. 
My  own  preference  is  for  chromicized  catgut,  which  can  be  boiled  with 
the  instruments  as  a  final  precaution,  using  no.  2  catgut  in  the  uterine 
musculature  and  in  the  fascia  of  the  abdominal  wall,  and  no.  i  for  the 
peritoneum.    It  must  be  remembered  that  chromicized  catgut,  even  when 


PREPARATIONS  FOR  OPERATION  lOI 

tied  in  a  square  knot  as  done  with  silk  or  linen  thread,  is  liable  to  slip 
and  become  untied  and  a  third  knot  should  be  tied  in  every  important 
suture.  Silkworm  gut  is  the  most  reliable  material  for  suturing  the 
skin  in  the  final  closure  of  the  abdominal  wall. 

The  usual  sterile  dressings  should  be  provided  and  large  gauze  hand- 
kerchiefs for  use  in  the  operation.  No  -small  sponges  should  be  allowed 
in  the  operation,  owing  to  the  fact  that  they  are  easily  lost  in  the 
abdominal  cavity,  to  make  trouble  later.  I  personally  prefer  gauze  strips, 
of  from  one  to  two  yards  in  length,  which  can  be  used  for  either  sponging 
or  packing  as  desired,  and  are  so  large  that  there  is  little  danger  that 
one  can  be  left  behind  at  operation.  That  this  danger  is  not  an  imaginary 
one  every  surgeon  knows,  although  he  expects  to  be  immune  himself. 
I  have  personally  removed  four  sponges  after  cesarean  section  by  other 
operators  and  know  of  several  other  instances. 

In  the  Boston  Lying-in  Hospital,  where  the  operative  assistants,  both 
interns  and  nurses,  are  constantly  changing,  the  following  routine  has 
been  adopted,  which  can  be  carried  out  easily  in  any  operating  room 
and  which  seems  to  me  to  leave  little  to  chance.  The  gauze  strips  are 
numbered  serially  from  one  to  twenty-five,  which  should  be  more  than 
are  needed  in  any  cesarean  section,  twelve  tO'  fifteen  being  usually  the 
maximum.  In  the  operating  room  we  have  a  wooden  frame  with  hooks 
numbered  to  correspond  with  the  numbered  sponges.  When  the  dry 
goods  are  opened  the  numbers  on  the  tags  sewed  to  the  sponges  are 
noted.  As  each  sponge  is  discarded  during  the  operation  it  is  hung  on 
the  hook  corresponding  to  its  number.  Before  the  abdomen  is  closed 
the  numbers  of  the  sponges  on  the  frame  and  clean  sponges  on  the  nurse's 
table  are  checked  up  and  the  operator  is  responsible  for  any  sponge  not 
thus  accounted  for.  At  the  end  of  the  operation  all  sponges,  used  and 
clean,  are  hung  on  their  proper  hooks  and  the  operator  can  see  at  a 
glance  that  none  are  missing. 

In  operations  in  private  houses  the  nurse  and  assistant  each  count  the 
sponges  twice  before  and  after  operation,  while  the  assistant  and  myself 
count  the  sponges  which  are  placed  in  the  abdomen  for  any  purpose,  both 
when  they  are  put  in  and  when  they  are  removed.  Before  the  abdomen 
is  closed  and  after  the  operation  is  completed  the  sponges  are  again 
counted,  and  the  count  must  agree  with  the  count  at  the  beginning  of 
operation  before  the  patient  is  put  to  bed. 

It  would  seem  as  if  there  should  be  no  necessity  to  insist  on  careful 
precautions  in  a  matter  of  such  great  importance  to  both  operator  and 
patient,  but  the  number  of  cases  in  which  sponges  are  left  in  the  abdomen 
after  operation  is  so  great  that  it  is  evident  that  many  surgeons  are 


102  CESAREAN  SECTION 

either  careless  themselves  or  trust  to  some  one  else  who  is  careless,  with 
unfortunate  results  for  the  patient  and  occasionally  for  the  surgeon, 
since  he  alone  must  bear  the  responsibility  for  such  neglect. 

Choice  of  Anesthetic. — All  of  the  recognized  methods  of  anes- 
thesia have  been  used  for  cesarean  section,  and  each  has  its  advantages 
or  disadvantages  in  the  different  types  of  case  for  which  cesarean  sec- 
tion may  be  indicated. 

General  Anesthesia. — In  patients  who  are  normal  surgical  risks 
the  use  of  a  general  anesthetic  is  the  most  satisfactory  method  for  the 
operator,  since  it  ensures  perfect  quiet  and  relaxation  on  the  part  of 
the  patient  and  does  away  with  any  fear  of  causing  undue  suffering  in 
the  manipulation  of  the  uterus. 

Chloroform  is  commonly  used  in  some  localities,  but  in  my  opinion 
has  no  advantages  over  ether  except  in  rare  cases,  and  sometimes  results 
fatally  for  the  patient.  The  immedate  dangers  of  chloroform  anesthesia 
are  too  well  known  to  require  discussion  here,  but  there  is  another  source 
of  danger  in  these  cases,  i.e.,  delayed  chloroform  poisoning.  A  certain 
number  of  cases  have  been  reported  after  profound  chloroform  anes- 
thesia, in  which  the  patient  has  died  a  few  days  later  with  symptoms 
analogous  to  those  of  toxemia  of  pregnancy,  and  at  autopsy  changes  in 
the  liver  have  been  demonstrated,  apparently  due  to  the  effect  of  the 
chloroform.  I  believe  it  to  be,  therefore,  an  unsafe  anesthetic  in  cesarean 
section  for  this  reason,  in  spite  of  the  fact  that  pregnant  women  are 
popularly  supposed  to  be  immune  to  the  ordinary  dangers  arising  from 
its  use.  The  liver  in  pregnancy  is  notoriously  liable  to  degeneration,  and 
no  drug  which  is  known  to  cause  liver  damage  under  any  circumstances 
should  be  employed,  unless  other  conditions  are  present  in  the  given  case 
which  may  render  the  advantages  from  the  use  of  chloroform  greater 
than  the  dangers  its  use  entails. 

Nitrous  oxid  gas  in  combination  with  oxygen  has  the  advantage 
of  producing  anesthesia  rapidly  and  of  being  eliminated  quickly.  It  is 
an  easy  method  of  anesthesia  for  the  average  patient  and  its  use  is  not 
usually  followed  by  vomiting,  although  in  susceptible  patients  vomiting 
may  be  severe  and  prolonged.  This  method  of  anesthesia  is  not,  how- 
ever, suited  for  prolonged  operations,  unless  the  anesthetist  has  had 
special  training  in  its  use,  and  the  evanescent  anesthesia  it  produces  may 
not  give  the  relaxation  necessary  for  a  prolonged  operation.  If  its  use 
is  preceded  by  morphia  and  scopolamin  it  may  prove  more  satisfactory, 
but  the  baby  is  apt  to  be  apneic  following  the  administration  of  morphia 
shortly  before  delivery  and  to  require  careful  resuscitation.  Its  employ- 
ment is  particularly  to  be  advised  in  patients  who  are  not  considered 


PREPARATIONS  FOR  OPERATION  103 

good  subjects  for  ether  on  account  of  irritative  conditions  of  the  air 
passages,  in  cases  in  which  the  use  of  a  general  anesthetic  is  deemed 
advisable.  Its  greatest  usefulness,  however,  is  as  a  preliminary  to  the 
use  of  ether  to  produce  full  anesthesia,  since  it  shortens  the  preliminary 
stages  and  does  away  with  much  of  the  discomfort  which  anesthesia  pro- 
duced by  ether  alone  entails. 

Gas-oxygen  anesthesia  should,  in  my  opinion,  never  be  used  on  pa- 
tients whose  blood  pressure  is  markedly  elevated.  The  stage  of  anesthesia 
is  preceded  by  a  short  stage  of  asphyxia,  which  produces  a  sudden  rise 
in  pressure  and  throws  a  sudden  burden  on  the  heart,  which  is  already 
working  hard.  Most  of  the  fatalities  reported  from  this  method  of 
anesthesia  have  occurred  in  cases  of  high  blood  pressure,  acute  cardiac 
dilatation  developing  as  a  result  of  the  sudden  increase  of  pressure.  This 
renders  it  an  unfit  anesthetic  for  use  in  the  toxemia  of  pregnancy  or 
chronic  nephritis.  For  the  same  reason  it  should  not  be  employed  as  a 
preliminary  to  ether  in  patients  who  have  serious  cardiac  lesions,  espe- 
cially if  the  myocardium  is  believed  to  be  diseased. 

Ether  is  the  best  of  the  general  anesthetics  and  is  practically  safe  for 
all  normal  patients.  In  irritative  conditions  of  the  lungs,  in  patients  with 
cardiac  decompensation,  and  in  diabetics,  its  use  is  attended  by  such 
danger  that  other  methods  of  producing  anesthesia  are  to  be  preferred. 
On  normal  women,  especially  when  preceded  by  gas,  its  use  is  not  at- 
tended by  risk  or  great  discomfort.  More  or  less  ether  passes  through 
the  placenta  to  the  fetus  and  at  times  seems  to  be  a  factor  in  rendering 
resuscitation  difficult,  but  this  effect  is  transient  and  not  productive  of 
harm. 

Local  Anesthesia. — In  patients  who  are  not  good  risks  for  a  gen- 
eral anesthetic,  i.e.,  patients  with  cardiac  decompensation,  diabetes, 
pneumonia,  etc.,  who  require  cesarean  section,  anesthesia  sufficient  for 
operation  can  be  produced  by  novocain,  either  injected  locally  into  the 
abdominal  wall,  or  used  by  the  paravertebral  or  intraspinous  methods. 

After  trying  the  various  methods  I  am  convinced  that  injection  of 
Yi.  per  cent  novocain  into  the  abdominal  walls,  infiltrating  all  layers 
thoroughly  and  waiting  a  reasonable  time — ten  to  fifteen  minutes  after 
the  injection  is  made — before  beginning  the  operation,  will  prove  more 
satisfactory  than  paravertebral  or  spinal  anesthesia.  In  a  somewhat 
limited  experience  by  this  method  I  have  found  satisfactory  relaxation 
of  the  abdominal  walls.  If  the  parietal  peritoneum  is  well  injected,  the 
abdominal  incision  can  be  made  practically  without  causing  pain  or 
even  marked  discomfort.  The  uterine  peritoneum  is  almost  non-sensitive 
and  can  be  incised  without  l^eing  infiltrated  with  novocain  almost  with- 


104  CESAREAN  SECTION 

out  sensation.  The  uterine  musculature  itself  also  seems  to  be  insensitive 
and  can  be  incised  without  being  anesthetized.  If  a  fairly  low  abdominal 
incision  is  made,  so  that  the  uterus  can  be  sutured  in  situ  without  being 
dragged  out  of  the  incision,  closure  of  the  wound,  including  the  peritoneal 
coat,  is  practically  painless.  The  anesthesia  of  the  abdominal  wall  lasts 
for  a  long  enough  time  to  render  closure  a  simple  matter  without  a  second 
infiltration.  If,  however,  there  are  peritoneal  adhesions  present  from 
old  inflammations  or  operations,  any  manipulation  of  them  is  exceedingly 
painful  and  the  attempt  to  infiltrate  them,  if  they  are  to  be  ligated  and 
divided,  causes  marked  pain,  although  with  care  it  can  be  accomplished. 
Although  the  uterus  is  practically  without  sensation,  any  attempt  to 
manipulate  the  broad  ligaments  or  tubes,  if  it  is  desired  to  sterilize  the 
patient,  causes  considerable  pain,  either  when  a  ligature  is  passed  through 
the  broad  ligament  or  when  it  is  tightened  around  the  tube,  but  the  tubes 
can  be  excised  from  the  uterus  without  causing  undue  suffering.  Hyster- 
ectomy under  local  anesthesia  would  probably  be  so  painful  as  to  be 
practically  impossible  without  infiltration  of  the  broad  ligaments  with 
the  novocain  solution,  but  simple  excision  of  the  tubes  from  the  uterine 
cornua  can  be  readily  accomplished. 

Paravertebral  anesthesia,  or  blocking  of  the  posterior  branches  of 
the  spinal  nerves  at  their  points  of  exit  from  the  spinal  foramina,  is  a 
satisfactory  method  of  producing  anesthesia  from  the  surgeon's  stand- 
point. It  labors  under  the  disadvantages  of  being  a  long  drawn  out 
process,  requiring  nearly  two  hours  to  produce  satisfactory  anesthesia 
for  operation,  and  furthermore  can  only  be  done  by  an  expert  who  has 
had  special  training  in  the  technic.  There  are  very  few  of  these  trained 
experts,  especially  in  this  country,  and  the  length  of  time  necessary  to 
produce  anesthesia  renders  it  inapplicable  to  emergency  cases. 

Spinal  anesthesia  is  a  satisfactory  method  as  far  as  producing  good 
anesthesia  for  the  operation.  The  after  effects,  headache,  vomiting,  etc., 
are  sometimes  very  unpleasant,  and  except  in  cases  in  which  extensive 
separation  of  adhesions  or  hysterectomy  may  be  necessary,  I  prefer  the 
local  anesthesia  as  the  more  satisfactory  method  in  the  comparatively  few 
cases  where  a  general  anesthetic  cannot  be  given. 

The  success  of  either  local  or  paravertebral  anesthesia  will  be  in- 
creased, if  the  patient  is  carefully  prepared  for  operation  by  the  use 
of  the  morphin-scopolamin  sequence.  Except  in  emergency  cases,  the 
patient  should  be  given  hypodermically  i/6  grain  of  morphia  and  1/200 
grain  of  scopolamin  from  one  and  one  half  to  two  hours  before  the  time 
set  for  operation.  The  scopolamin,  but  not  the  morphia,  should  be 
repeated  at  intervals  of  forty-five  minutes,  more  than  two  additional 


PREPARATIONS  FOR  OPERATION  105 

doses  being  seldom,  if  ever,  necessary  to  make  even  the  most  nervous 
patient  quiet  and  so  drowsy  that  she  drops  off  to  sleep  on  being  left  to 
herself.  As  an  added  precaution,  her  ears  are  plugged  with  cotton  and 
her  eyes  are  bandaged  just  before  she  is  brought  to  the  operating  room. 
When  a  patient  is  so  prepared,  it  is  often  possible  to  anesthetize  the 
abdominal  wall  without  rousing  her  to  consciousness,  except  very  tem- 
porarily, and  the  operation  can  be  performed  with  a  minimum  of  suffer- 
ing, if  the  operator  is  careful  to  wait  a  proper  length  of  time  for  the 
novocain  anesthesia  to  develop,  and  then  is  careful  to  be  gentle  in  his 
intra-abdominal  manipulations,  particularly  avoiding  traction  on  the 
pelvic  peritoneum  and  in  handling  the  broad  ligaments. 

The  recovery  from  the  immediate  effects  of  the  operation  is  notice- 
ably painless  and  free  from  shock,  even  in  hypersensitive  patients,  and 
there  is  no  tendency  to  postoperative  vomiting.  This  method  is,  in  my 
opinion,  particularly  suited  to  cardiac  patients  in  whom  more  or  less 
serious  decompensation  is  present,  although  some  authorities  consider  the 
use  of  morphin  and  scopolamin  dangerous  in  such  circumstances.  In  my 
experience,  however,  the  method  has  been  a  success,  and  there  have  been 
no  uncomfortable  symptoms  in  the  small  number  of  cases  in  which  I 
have  employed  it. 


CHAPTER  VIII 

OPERATION 

The  Classical  Cesarean  Section — Use  of  Oxytocics — Abdominal  Incision ;  High ;  Low — 
Technic  of  Operation — Question  of  Haste — Protection  of  Peritoneal  Cavity — 
Uterine  Incision — Extraction  of  Child  and  Placenta — Suture  of  Uterine  Incision 
— Peritoneal  Toilet — Precautions  Against  Postpartum  Hemorrhage — Closure  of 
Abdominal  Wound — Transverse  Fundal  Incision  of  Uterus;  Advantagec;  Dis- 
advantages— Gastric   Lavage   to    Diminish    Postoperative   Vomiting — Bibliography. 

In  the  ordinary  case  the  conservative,  or  classical,  cesarean  section 
is,  from  a  purely  technical  standpoint,  a  simple,  surgical  procedure.  The 
abdomen  is  opened  in  the  mid  line,  or  slightly  to  one  side  of  it;  the 
uterus  is  opened  in  the  median  line ;  the  child  and  placenta  are  extracted ; 
the  uterus  is  sutured  and  replaced  in  the  abdominal  cavity,  and  the 
abdomen  is  closed.  It  is  a  simple  operation  in  the  absence  of  complica- 
tions, usually  to  be  completed,  in  the  ordinary  case,  inside  of  half  an 
hour.  The  steps  of  the  operation,  however,  must  be  described  more  in 
detail,  since  certain  points  in  technic  may  render  the  results  more  satis- 
factory. 

It  is  customary  to  administer  to  the  patient,  shortly  before  the  in- 
cision is  made  in  the  uterus,  a  hypodermic  injection  of  some  reliable 
preparation  of  ergot,  or  pituitary  extract,  or  both,  to  aid  in  securing 
proper  contraction  and  retraction  of  the  uterus  after  the  child  is  de- 
livered, for  the  purpose  of  preventing  or  limiting  hemorrhage,  which 
may  occasionally  be  very  severe  in  a  relaxed  condition  of  the  organ. 

The  time  and  method  of  administration  varies  with  different  opera- 
tors and  should  vary  with  different  patients.  A  combination  of  ergot 
and  pituitary  extract  is  more  efficient  than  either  alone,  since  they  differ 
markedly  in  the  rapidity  and  duration  of  their  action.  Ergot  is  a 
relatively  slow  acting  drug,  and  its  effect  is  prolonged,  whereas  the 
pituitary  extract  acts  quickly  and  its  action  is  comparatively  transient, 
and  if  used  alone,  postpartum  hemorrhage  may  follow  when  the  effect 
of  the  drug  wears  off. 

In  a  patient  who  is  not  in  labor  and  in  whom  the  contraction  of  the 
uterus  is  apt  to  be  rather  slow  it  is  my  custom  to  give  one  ampul  of 
so*ne  reliable  preparation  of  aseptic  ergot  deep  into  the  muscles  of  the 

io6 


OPERATION  107 

thigh  shortly  after  the  anesthetic  is  started,  timing  it  so  that  practically 
ten  minutes  will  elapse  from  the  time  of  administration  to  the  beginning 
of  operation,  and  to  inject  one  ampul  of  pituitary  extract  into  the 
uterine  wall  just  before  it  is  incised.  A  second  ampul  of  ergot  is  given 
before  the  patient  is  returned  to  bed  as  a  matter  of  precaution,  to  ensure 
contraction  of  the  uterus  until  thrombosis  has  taken  place  in  the  uterine 
sinuses  and  the  danger  of  postpartum  hemorrhage  is  past. 

In  patients  who  have  had  previous  abdoniinal  operations  and  in  whom 
there  may  be  adhesions,  the  separation  of  which  may  require  some  time 
before  the  uterus  can  be  opened,  I  prefer  to  give  the  ergot  just  l3efore 
beginning  the  abdominal  incision,  to  avoid  any  possibility  that  by  an 
unusually  prompt  action  it  may  induce  spasm  of  the  uterus  prematurely, 
and  thus  interfere  with  the  placental  interchange  and  produce  a  degree 
of  asphyxia  in  the  child  which  may  materially  interfere  with  its  resusci- 
tation. This  is  a  point  of  some  practical  importance,  since  it  is  a  matter 
of  common  experience  that  an  unusually  prompt  action  from  either  ergot 
or  pituitary  extract  may  cause  such  a  severe  contraction  of  the  uterine 
muscle  as  to  render  extraction  of  the  child  and  placenta  difficult,  unless 
a  much  more  extensive  incision  is  made  than  is  ordinarily  necessary  for 
delivery;  and  if  is  conceivable  in  such  a  case  that,  if  much  time  were 
wasted  in  freeing  adhesions,  death  of  the  child  might  occur  from  inter- 
ference with  the  placental  circulation. 

If  the  patient  is  in  labor  at  the  time  of  operation,  the  uterus  will 
probably  contract  and  retract  in  a  satisfactory  manner  without  the  aid 
of  oxytocic  drugs,  and  the  administration  of  the  ergot,  being  simply  a 
precaution  to  prevent  postpartum  hemorrhage,  may  be  delayed  until  the 
abdomen  is  opened,  since  if  it  should  happen  to  act  unusually  promptly 
on  an  irritable  uterus,  it  may  render  the  extraction  of  the  child  difficult ; 
and  it  is  conceivable  that  sufficient  interference  with  the  placental  circula- 
tion might  be  induced  by  too  rapid  action  to  turn  the  scale  against  a 
child  which  had  already  suffered  from  a  more  or  less  prolonged  labor. 

Some  operators  prefer  to  depend  on  pituitary  extract  alone,  injecting 
it  directly  into  the  uterine  muscle  just  before  the  uterine  incision  is  made. 
Administered  in  this  way,  its  action  is  prompt  and  satisfactory,  but  since 
its  action  is  relatively  transient,  I  feel  that  its  use  should  be  reinforced  by 
the  intramuscular  injection  of  ergot,  to  prevent  possible  relaxation  of 
the  uterus  with  postpartum  hemorrhage. 

Incision  of  the  Abdomen. — There  has  been  much  discussion  in  the 
last  few  years  as  to  whether  the  abdominal  incision  should  be  made  above 
or  below  the  umbilicus,  but  either  incision  is  perfectly  satisfactory  in  the 
average  patient.     In  certain  types  of  patient,  however,  the  location  of 


io8  CESAREAN  SECTION 

the  incision  is  of  importance,  because  of  various  conditions  which  may 
be  present,  and  these  conditions  require  some  discussion.  If  an  extra- 
peritoneal operation  is  contemplated,  so  that  the  uterine  incision  will 
be  in  the  lower  segment,  a  low  incision  must  be  made,  but  in  the  average 
clean  case  the  location  of  the  incision  is  practically  immaterial. 

In  the  early  days  of  cesarean  section  a  long  incision  was  employed, 
reaching  from  the  ensiform  to  the  pubes,  and  the  uterus  was  delivered 
from  the  abdominal  cavity  before  being  incised,  the  peritoneal  cavity 
being  carefully  protected  by  gauze  packing  to  prevent  contamination  by 
blood  and  liquor  when  the  uterus  was  opened.  The  long  incision  has 
been  practically  abandoned  at  the  present  time  in  favor  of  an  incision 
just  long  enough  to  permit  the  easy  delivery  of  the  child,  and  it  is 
customary  to  incise  the  uterus  in  situ,  except  in  cases  believed  to  be 
infected.  In  this  case,  however,  a  sufficiently  long  incision  should  be 
used  to  permit  the  delivery  of  the  uterus  before  it  is  opened,  and  the 
peritoneal  cavity  should  be  carefully  protected  by  gauze  packing.  Fur- 
thermore, in  these  cases  the  operation  is  best  completed  by  amputation  of 
the  uterus,  instead  of  returning  it  to  the  abdominal  cavity  to  act  as  a 
source  of  infection  and  general  peritonitis. 

High  Incision. — The  advocates  of  the  high  incision  urge  that  the 
incision  be  entirely  above  the  umbilicus,  claiming  that  adhesions  between 
the  uterine  and  abdominal  incisions  are  thus  avoided,  since  the  empty 
uterus  promptly  retracts  below  the  level  of  the  umbilicus,  and  that  hernia 
in  a  scar  in  this  region  very  seldom  occurs  and  if  it  does  occur  causes 
little  or  no  inconvenience  to  the  patient.  The  disadvantages  of  the  high 
incision  lie  in  the  fact  that,  if  it  becomes  necessary  to  remove  the  uterus 
for  any  reason  which  develops  during  operation,  the  incision  must  be 
widely  extended ;  and  it  also  seems  to  me  that  dilatation  of  the  stomach 
occurs  somewhat  more  often  as  a  postoperative  complication,  if  the  high 
incision  is  employed.  A  relatively  high  incision,  however,  has  a  very 
distinct  advantage  in  patients  with  fat  abdominal  walls,  since  the  fat 
layer  is  much  thinner  above  than  below  the  umbilicus  and  the  operation 
is  thus  made  more  easy ;  but  in  the  average  case  I  believe  that  the  location 
of  the  incision  is  not  a  matter  of  great  moment. 

Low  Incision. — The  advocates  of  the  low  incision  simply  say  that 
it  has  proved  satisfactory  in  their  hands,  that  the  uterus  has  not  be- 
come adherent  to  the  scar  in  clean  cases,  that  hernia  in  the  scar  does 
not  occur  in  their  experience,  if  the  abdominal  wall  is  properly  sutured, 
and  that  from  their  standpoint  the  high  incision  offers  no  advantages. 

I  personally  prefer.  In  clean  cases,  an  incision  with  the  umbilicus  at 
about  the  mid  point,  usually  to  the  right  of  the  mid  line,  since  the  uterus 


OPERATION  109 

is  twisted  to  the  right  in  about  80  per  cent  of  all  cases,  and  this  incision 
is  thus,  in  the  majority  of  cases,  more  nearly  over  the  mid  line  of  the 
uterus  where  the  uterine  incision  is  best  made.  An  incision  at  this  level 
removes  the  uterine  incision  from  the  relatively  inactive  lower  segment 
and  the  bladder  attachment,  which  I  believe  to  be  an  advantage,  and  the 
incision  is  high  enough  to  prevent  adhesion  of  the  uterus  to  the  wound. 

Conduct  of  the  Operation. — There  seems  to  be  something  about 
cesarean  section  which  induces  a  large  proportion  of  operators  to  hurry 
as  no  other  operation  does,  and  the  operation  often  becomes  a  mad 
scramble  in  the  attempt  to  deliver  the  baby  in  the  shortest  possible  time. 
I  know  of  at  least  two  instances  in  which  the  baby  has  been  cut  during 
the  primary  skin  incision,  which  is  unpardonable.  The  operator  must 
remember  that  although  the  intestines  lie  behind  and  to  the  sides  of  the 
uterus  in  practically  all  cases  in  which  there  are  no  adhesions  from  pre- 
vious operations  or  inflammatory  conditions,  sudden  straining  on  the 
patient's  part  at  the  time  of  the  incision  of  the  abdomen  may  force  a 
loop  of  intestine  in  front  of  the  uterus  into  a  position  where  it  may  be 
injured,  if  the  abdominal  incision  is  rashly  made. 

In  patients  who  have  had  previous  abdominal  operations  the  danger 
is  a  very  real  one,  since  it  is  not  at  all  uncommon  to  find  a  loop  of 
intestine  adherent  to  the  old  incision  or  to  the  uterine  scar  in  a  position 
where  it  might  very  readily  be  injured  if  the  abdominal  wall  is  opened 
carelessly,  and  though  I  do  not  know  of  any  case  in  which  the  intestine 
has  been  injured,  I  have  seen  several  cases  in  which  it  might  well  have 
been,  except  for  care  exercised  by  the  operator.  There  is  no  more 
reason  for  haste  in  cesarean  section  than  in  other  laparotomies,  and  the 
abdominal  wall  should  be  opened  deliberately  by  an  incision  approximately 
six  inches  in  length.  The  uterus  will  then  lie  exposed  directly  under  the 
incision.  Since  a  certain  degree  of  torsion  of  the  uterus  is  usually  pres- 
ent, the  uterus  should  be  palpated  to  ascertain  its  position  as  well  as  the 
position  of  the  child,  and  if  much  lateral  torsion  exists,  it  should  be 
brought  into  an  approximately  normal  position  before  being  opened,  in- 
asmuch as  if  the  uterine  incision  is  made  in  the  region  of  one  of  the 
cornua,  more  hemorrhage  is  to  be  expected  on  account  of  the  large  ves- 
sels in  that  region  than  if  it  is  opened  close  to  the  median  line. 

Before  incising  the  uterus  some  operators  prefer  to  protect  the 
peritoneal  cavity  by  gauze  packs  moistened  with  normal  saline  solution. 
In  perfectly  clean  cases  this  is  unnecessary,  since  the  uterine  contents 
are  sterile,  except  possibly  in  cases  of  toxemia  and  eclampsia,  in  which 
recent  observations  tend  to  show  a  blood  infection  in  a  considerable 
number  of  cases.     In  doubtful  cases  the  peritoneal  cavity  should  always 


no  CESAREAN  SECTION 

be  protected  before  the  uterus  is  opened.  Usually,  however,  all  that  is 
necessary  for  protection  of  the  peritoneum  is  to  compress  the  abdominal 
walls  against  the  uterus,  so  that  most  of  the  liquor  and  blood  will  escape 
externally,  the  remainder  being  removed  at  the  end  of  operation,  when 
a  careful  peritoneal  toilet  should  be  performed  in  any  case.  If  the 
patient  is  believed  to  be  infected,  the  abdominal  incision  should  be  of 
sufficient  length  to  permit  the  delivery  of  the  unopened  uterus,  and  the 
peritoneal  cavity  should  be  carefully  protected  by  packing  before  the 
uterus  is  incised.  In  such  a  case  the  greater  part  of  the  incision  should 
be  below  the  umbilicus,  to  permit  of  easy  access  to  the  broad  ligaments, 
etc.,  in  case  it  is  decided  to  complete  the  operation  by  hysterectomy. 

Uterine  Incision. — A  longitudinal  incision  is  now  made  through  the 
uterine  wall  in  the  median  line,  a  few  centimeters  in  length,  down  to  the 
membranes  or  placenta,  if  the  latter  is  situated  on  the  anterior  wall,  and 
rapidly  enlarged  with  scissors  to  a  length  sufficient  for  the  easy  extraction 
of  the  child.  If  the  incision  is  not  long  enough,  it  will  tear  at  one  or 
both  ends,  leaving  a  ragged  wound,  the  efficient  suture  of  which  may 
prove  a  matter  of  considerable  difficulty.  In  a  considerable  propor- 
tion of  cases  the  placenta  will  be  found  lying  under  the  uterine  incision, 
but  this  is  of  no  moment  except  that  the  immediate  loss  of  blood  is 
greater  than  if  the  placenta  lies  on  the  posterior  wall  of  the  uterus,  on 
account  of  the  increased  vascularity  of  the  uterine  wall  in  the  region  of 
the  placenta.  If  the  placenta  lies  under  the  incision  it  should  be  pushed 
to  one  side  or  perforated  and  the  hand  passed  rapidly  down  to  the  feet 
of  the  child,  which  have  been  previously  located,  and  one  or  both  feet 
grasped  and  the  child  rapidly  extracted.  If  the  placenta  is  not  under 
the  incision,  the  membranes  will  bulge  through  the  wound.  They  should 
be  ruptured  and  the  child  rapidly  extracted.  The  only  period  of  danger 
for  the  child  is  in  the  period  between  the  beginning  of  the  uterine  incision 
and  the  extraction  of  the  child,  especially  in  cases  in  which  extensive 
separation  of  the  placenta  from  the  uterine  wall  is  necessary  before  the 
hand  can  be  introduced  into  the  uterine  cavity ;  and  this  is  the  only  por- 
tion of  the  operation  in  which  rapid  manipulation  is  of  advantage.  The 
entire  procedure  of  extraction  of  the  child  should  only  take  a  few  seconds, 
however,  and  there  should  be  little  or  no  danger  to  a  child  whose  con- 
dition has  not  been  compromised  before  the  operation  is  undertaken, 
unless  the  attempt  is  made  to  extract  it  through  too  small  an  opening  in 
the  uterine  wall.  It  is,  therefore,  important  that  the  uterine  incision 
should  be  sufficiently  long  to  permit  easy  extraction  and  avoid  any  pos- 
sible delay. 

As  soon  as  the  child  is  delivered  the  cord  should  be  clamped  in  two 


OPERATION 


III 


Fig.  29. — Conservative  Cesarean  Section. 
Uterine  incision :   fetal  membranes  visible. 


places  and  cut  between  the  clamps.  The  child  should  then  be  handed 
promptly  to  the  assistant  responsible  for  its  resuscitation,  and  the  operator 
can  then  devote  his  whole  attention  to  the  completion  of  the  operation. 
The  uterus  should  now  be  delivered  through  the  abdominal  wound  and  a 


112 


CESAREAN  SECTION 


gauze  pack  or  folded  towel  inserted  behind  it,  to  prevent  any  further 
peritoneal  contamination.  There  will  always  be  a  certain  amount  of 
bleeding  from  the  uterine  incision,  and  sometimes  large  sinuses  will  be 
seen  bleeding  freely,  but  as  soon  as  the  uterus  begins  to  contract  and 
retract  the  bleeding  w^ill  be  largely  controlled,  and  in  my  experience  it  is 
seldom  or  never  necessary  to  take  any  active  steps  to  control  the 
hemorrhage.     In  the  early  days  of  the  operation  it  was  considered  ad- 


FiG.  30. — Conservative  Cesarean  Section. 

Uterus,  emptied  of  fetus,  delivered  through  abdominal 
wall  and  lying  upon  gauze :  placenta  undelivered. 

visable  to  compress  the  lower  segment  of  the  uterus  by  an  elastic 
tourniquet,  but  further  experience  has  shown  this  to  be  not  only  un- 
necessary but  even  positively  harmful,  though  some  operators  still  em- 
ploy compression  of  the  cervix  made  by  the  hands  of  an  assistant  in 
the  broad  ligament  regions,  with  the  idea  that  if  the  uterine  arteries 
are  compressed  in  this  way,  there  will  be  little  or  no  hemorrhage  from 
the  uterine  incision  during  the  process  of  suture,  and  that  all  danger 
from  hemorrhage  ceases  as  soon  as  the  uterine  wound  is  closed.  This 
procedure  has  the  disadvantage  of  being  unnecessary  in  most  cases  and  of 


OPERATION  113 

subjecting  the  pelvic  peritoneum  to  an  undue  amount  of  handling,  which 
can  be  avoided  in  all  but  the  occasional  case,  and  the  less  the  peritoneum 
is  manipulated  the  more  comfortable  the  convalescence.  Furthermore, 
when  the  lower  segment  of  the  uterus  is  tightly  compressed,  whether  by 
the  hands  of  an  assistant  or  by  a  rubber  tourniquet,  it  seems  to  partially 
paralyze  the  uterine  muscle  and  temporarily  diminish  its  contractility, 
thus  interfering  with  its  normal  contraction  and  retraction,  at  times  to  a 
degree  which  definitely  predisposes  to  postpartum  hemorrhage,  ultimately 
increasing  instead  of  lessening  the  amount  of  blood  lost. 

As  soon  as  the  uterus  is  delivered  the  placenta  and  membranes  should 
be  removed,  great  care  being  taken  to  detach  and  remove  all  of  the 
membranes,  particularly  those  in  the  lower  uterine  segment,  the  reten- 
tion of  which-  may  interfere  with  proper  drainage  of  the  lochia  later  by 
acting  as  a  plug,  which  obstructs  the  cervical  canal  and  thus  predisposes 
to  retention  of  lochia,  at  times  to  a  degree  which  may  give  rise  to  un- 
comfortable symptoms  and  necessitate  active  treatment. 

Suture  of  the  Uterine  Incision. — The  uterine  wound  should  now  be 
sutured  according  to  the  technic  of  the  individual  operator,  the  points  to 
be  observed  being  complete  closure  of  the  wound  in  the  uterine  muscula- 
ture and  careful  suture  of  the  peritoneum  over  it.  To  accomplish  this  I 
prefer  interrupted  chromic  catgut  sutures  about  one  centimeter  apart 
which  include  the  whole  thickness  of  the  uterine  wall  from  the  peritoneum 
to,  but  not  including,  the  decidual  lining.  These  sutures  are  tied  only 
sufficiently  tightly  to  compress  the  included  muscle  without  causing 
necrosis.  Coaptation  sutures  should  be  placed  superficially,  if  necessary, 
to  secure  proper  approximation  of  the  muscle.  I  believe  it  to  be  im- 
portant that  the  stitches  placed  at  the  upper  and  lower  angles  of  the 
wound  should  be  so  placed  as  to  include  any  sinuses  which  may  enter 
the  angles  of  the  wound,  since  if  this  precaution  is  neglected,  trouble- 
some bleeding  may  occur.  The  uterine  peritoneum  is  then  closed  over 
the  wound  with  a  continuous  suture.  Any  packing  which  has  been  in- 
serted into  the  abdominal  cavity  is  removed  and  the  peritoneal  cavity 
carefully  cleansed  of  any  liquor  or  blood  which  may  have  escaped  into 
it,  and  the  abdominal  wall  closed  in  layers. 

Transverse  Incision  of  the  Fundus. — In  1897  Fritsch  suggested 
that  a  transverse  fundal  incision  be  substituted  for  the  ordinary  longitu- 
dinal median  incision  of  the  uterus,  on  the  theory  that,  since  the  course 
of  the  blood  vessels  in  that  region  is  largely  transverse,  large  vessels  are 
less  likely  to  be  injured  and  hemorrhage  will  be  minimized.  Many 
operators  have  followed  his  lead,  Ijut  the  results,  though  excellent,  have 


114 


CESAREAN  SECTION 


not  proved  to  be  any  better  than  those  obtained  by  the  ordinary  incision, 
and  to-day  it  is  practically  abandoned. 

It  has  been  urged  that,  if  the  incision  is  made  in  this  regi'on,  the 
adhesions  between  the  uterine  and  abdominal  incisions  are  eliminated. 
This  is  undoubtedly  true,  but  the  fact  that  the  liability  to  adhesion  be- 
tween intestine  or  omentum  and  the  uterine  incision  is  much  increased 


Fig.  31. — Conservative  Cesarean  Section. 
Placenta  delivered  and  deep  sutures  inserted. 

renders  this  advantage  of  distinctly  minor  importance.  Furthermore, 
it  is  evident  that,  in  case  of  infection  of  the  uterine  incision,  the  peritoneal 
cavity  is  to  a  certain  extent  protected  by  the  fact  that  the  uterine  in- 
cision may  become  adherent  to  the  abdominal  wall,  and  if  an  abscess 
forms  it  can  be  drained  v^ith  ease  through  the  abdominal  incision,  or 
an  extension  of  it,  whereas,  if  the  fundal  incision  were  employed,  the 
septic  material  would  escape  directly  into  the  general  peritoneal  cavity, 


OPERATION 


115 


causing  peritonitis  and  death.  In  perfectly  clean  cases  this  risk  is  a 
small  one,  but  when  there  is  the  slightest  doubt  as  to  whether  infection 
is  present  or  not,  the  transverse  incision  is  absolutely  contra-indicated. 

The  only  real  advantage  of  this  incision  would  seem  to  be  in  cases  in 
which  it  is  proposed  to  sterilize  the  patient  by  excision  of  the  tubes  from 
the  uterine  cornua,  which  can  be  accomplished  by  a  single  incision  in 
this  location.     The  advantages  gained  by  this  method  are,   however. 


Fig.  32. — Conservative  Cesarean  Section. 

Deep  sutures  buried :  external  muscle  and  peritoneum 
joined  by  continuous  suture. 

rather  apparent  than  real,  whether  as  regards  saving  of  time  or  ease 
of  performance. 

Within  the  last  few  years  certain  operators  have  advocated  that  the 
uterine  incision  should  be  made  in  the  lower  uterine  segment,  even  in 
absolutely  clean  cases,  the  bladder  being  separated  from  the  anterior 
surface  of  the  uterus  to  expose  the  field  of  operation  and  replaced  after 
the  suture  of  the  uterine  wound  is  completed.     The  advantages  claimed 


ii6  CESAREAN  SECTION 

are,  that  the  uterine  incision,  being  walled  off  from  the  peritoneal  cavity, 
convalescence  is  smoother  and  more  comfortable  for  the  patient  in  clean 
cases,  and  that  if  infection  of  the  uterine  wound  occurs,  it  will  remain 
extraperitoneal  and,  therefore,  be  less  serious  than  if  the  wound  con- 
nects directly  with  the  peritoneal  cavity.  It  is  also  claimed  that  the 
wound,  being  in  the  passive  portion  of  the  uterus,  is  less  affected  by  the 
alternating  periods  of  contraction  and  relaxation  which  occur  in  the 
active  portion  of  the  uterus  and,  therefore,  will  heal  more  satisfactorily 
and  ultimately  give  a  jfirmer  scar,  which  will  be  less  liable  to  rupture  in 
future  pregnancies. 

The  advantages  to  be  gained  in  clean  cases  at  the  time  of  election 
from  this  modification  seem  to  me  to  be  theoretical  rather  than  real, 
with  the  possible  exception  that  in  some  cases  the  convalescence  will  be 
made  somewhat  smoother,  and  the  technic  of  operation  is  distinctly  more 
difficult.  Furthermore,  troublesome  bleeding  sometimes  occurs  from 
injury  to  veins  in  this  region  and  its  control  may  prove  a  matter  of 
considerable  difficulty. 

There  is  no  question  but  that,  if  infection  c^f  the  uterine  wound  oc- 
curs, a  localized  process  between  the  uterus  and  bladder  will  be  less  im- 
mediately dangerous  to  the  patient  than  if  the  infected  uterine  wound 
communicates  directly  with  the  general  peritoneal  cavity,  but  this  alter- 
native does  not  often  arise  in  cases  operated  on  at  the  time  of  election, 
and,  in  my  opinion,  this  operation  should  be  reserved  for  patients  to 
whom  the  classical  cesarean  section  seems  to  offer  undue  risks,  and  yet 
for  whom  cesarean  section  by  some  method  seems  to  be  definitely  indi- 
cated. This  group  includes  patients  who'  have  been  subjected  to  a 
prolonged  labor  and  those  who  have  been  repeatedly  examined  vaginally, 
even  under  good  asepsis.  It  does  not  include,  however,  those  who  are 
frankly  infected,  for  whom  cesarean  section  should  be  avoided  if  pos- 
sible, and  when  it  seems  unavoidable  should  be  followed  by  hysterectomy. 

It  has  been  advised  by  some  operators  that  the  cervix  should  be 
dilated  from  above  to  ensure  free  drainage  for  the  lochia  before  the 
uterine  wound  is  closed,  but  this  is  unnecessary  in  most  cases,  and 
unless  the  vagina  has  been  surgically  prepared,  is  a  possible  source  of 
danger  to  the  patient.  Furthermore  efficient  cervical  dilatation  will  often 
prove  difficult  and  may  be  attended  by  so  much  trauma  as  to  offer  a 
portal  for  infection  and  thus  increase  the  danger  to  the  patient.  Vaginal 
preparation  should  always  be  carried  out  in  cases  that  have  been  long 
in  labor  or  that  have  had  vaginal  interference  before  the  abdominal 
operation  is  undertaken,  but  is  not  otherwise  necessary,  and  in  these 
cases  I  believe  that  it  is  a  wise  precaution  to  irrigate  the  lower  portion 


OPERATION  117 

of  the  uterine  cavity  with  70  per  cent,  alcohol,  which  is  allowed  to  drain 
away  through  the  cervix. 

The  vaginal  preparation  should  consist  of  a  thorough  scrubbing  with 
sterile  soap  and  water  followed  by  alcohol,  as  for  any  vaginal  operation. 
Douching  with  antiseptic  solutions  is  an  unreliable  method  of  securing 
vaginal  asepsis,  and  only  a  thorough  scrub  under  anesthesia  is  to  be 
relied  on. 

Before  the  abdominal  wall  is  closed  the  lower  uterine  segment  should 
be  palpated,  and  if  it  is  found  filled  with  clots,  as  is  often  the  case,  they 
should  be  milked  out  through  the  cervix.  The  uterus  should  be  watched 
carefully  and  kneaded  from  time  to  time,  to  ensure  efficient  contraction\ 
as  a  guarantee  against  hemorrhage,  and  the  abdomen  should  not  be 
closed  until  satisfactory  contraction  has  been  obtained,  which  may  in 
some  cases  require  some  little  delay.  Most  of  the  cases  of  serious  post- 
partum bleeding  have  occurred  in  cases  in  which  the  condition  of  the 
uterus  was  not  carefully  ascertained  before  the  abdomen  was  closed,  and 
the  uterus  should  always  be  palpated  to  learn  its  condition  just  before 
the  peritoneal  closure  is  completed.  The  abdominal  wall  is  closed  in 
layers,  the  skin  being  carefully  approximated.  The  method  of  closure 
depends  on  the  preferences  of  the  individual  operator,  any  carefully 
done  layer  suture  being  efficient. 

While  the  final  layer  of  sutures  is  being  placed  in  the  abdominal  wall 
I  always  adopt  the  precaution  of  washing  out  the  patient's  stomach  in 
the  hope  of  removing  any  ether  which  may  have  been  secreted  into  the 
stomach  during  operation,  which  may  act  as  an  irritant  and  increase  the 
tendency  to  postoperative  vomiting.  The  results  of  this  treatment  seem 
to  warrant  its  continuance,  as  few  of  my  patients  are  troubled  with 
vomiting  during  the  twenty-four  hours  immediately  after  operation,  and 
the  avoidance  of  retching  makes  them  much  more  comfortable.  There 
is  a  small  proportion,  however,  in  whom  nothing  seems  to  affect  the 
postoperative  vomiting.  Many  of  these  patients  vomit  excessively  after 
gas-oxygen  anesthesia,  so  that  it  is  apparently  some  condition  of  the 
gastro-intestinal  tract,  rather  than  the  anesthetic,  which  is  responsible. 

After  the  abdominal  wound  is  closed  the  dressing  is  applied  and  the 
patient  put  to  bed,  usually  being  given  one  sixth,  or  a  quarter  of  a  grain 
of  morphia  as  soon  as  she  becomes  restless  and  begins  to  show  signs  of 
recovery  from  anesthesia.  Unless  the  patient  gives  a  history  of  un- 
comfortable reaction  to  morphia  in  the  past,  the  dosage  is  repeated  as 
often  as  may  be  necessary  for  the  next  twenty-four  hours,  bearing  the 
fact  in  mind  that  if  severe  postoperative  vomiting  develops  morphia  may 
\)C  a  causative  factor  in  susceptible  individuals. 


ii8  CESAREAN  SECTION 

The  technic  of  supravaginal  hysterectomy  and  extraperitoneal  cesa- 
rean section  will  be  considered  in  separate  chapters. 


LITERATUEE 

Bar.     De    roperation    cesarienne    conservative.     L'obstetrique.      1899. 

4:  193- 
Fritsch.     Ein  Netier  Schnitt  bei  der  Sectio  Caesarea.     Centrbl.  f.  Gyn. 

1897.     21  :  561. 
FoMON,  S.    In  Medicine  and  the  Allied  Sciences.    3  :  ']2.. 
Garrigues,  H.  J.     The  Technique  of  the  Improved  Caesarean  Section. 

Int.  Jr.  of  Surg.     March,  1896. 
Peradon,  a.     Contribution  a  I'etude  de  I'operation  cesarienne  moderne: 

indications;   technique   operatoire;   resultats;   suites  operatoires; 

statistique.     Paris,   1913. 


CHAPTER  IX 


AFTER  CARE 


Relief  of  Pain — Thirst — Diet — Care  of  Bladder — Bowels — Intestinal  Distention — 
Lochia — Treatment  of  Returned  Lochia — Antiseptic  Precautions — Vaginal  Douches 
Contra-indicated — Lactation  and   Nursing — Temperature — Pulse — Bibliography. 

The  after  care  of  the  patient  who  has  had  a  cesarean  operation  is  a 
combination  of  the  care  of  an  ordinary  laparotomy,  plus  the  usual  pre- 
cautions carried  out  after  a  normal  delivery.  There  are  certain  com- 
plications which  are  apt  to  arise  and  which  must  be  guarded  against  or 
watched  for,  since  they  may  cause  considerable  anxiety  and,  if  neglected, 
may  prove  serious.  This  is  particularly  true  in  patients  who  have  been 
in  labor  for  any  length  of  time  and  have  been  subjected  to  frequent 
examination,  but  the  simplest  case  may  give  rise  to  symptoms  which 
will  cause  serious  anxiety.  As  a  general  rule  the  recovery  from  the 
anesthetic  is  prompt  and  attended  by  little  or  no  vomiting,  if  the  stomach 
has  been  washed  out  before  the  patient  leaves  the  table;  in  fact,  as  in 
other  obstetric  operations,  there  would  seem  to  be  less  nausea  and 
vomiting  than  in  other  cases  where  ether  is  given  to  full  anesthesia. 

Pain. —  Many  patients  suffer  severely  from  pain  during  the  first  few 
hours  after  operation,  and  repeated  doses  of  morphia  may  be  required 
to  keep  the  patient  quiet  and  fairly  comfortable,  and  may  be  used  with- 
out hesitation. 

Two  factors  seem  to  enter  into  the  causation  of  pain,  the  wound  itself 
and  the  so-called  after  pains,  due  to  repeated  contraction  and  relaxation 
of  the  uterus.  The  pain  from  the  wound  is  ordinarily  easily  controlled, 
but  in  the  occasional  patient,  usually  a  multipara,  the  after  pains  cause 
marked  discomfort,  and  the  patient  complains  bitterly.  In  one  of  my 
patients  recurrent  uterine  contractions  at  short  intervals  caused  so  much 
suffering  as  to  render  necessary  the  administration  of  one  and  one 
fourth  grains  of  morphia  in  divided  doses  before  any  appreciable  relief 
was  obtained.  In  these  cases  repeated  doses  of  morphia  at  short  intervals 
may  be  required  to  make  the  patient  comfortable,  and  should  be  given, 
if  necessary,  during  the  first  twenty- four  hours.  After  this  time  morphia 
is  seldom  necessary,  and  any  discomfort  which  remains  can  usually  be 
controlled  by  codeia,  which  is  less  likely  to  cause  intestinal  paralysis,  and 

119 


120  CESAREAN  SECTION 

is  to  be  preferred.  In  the  comparatively  rare  case  in  which  severe  and 
prolonged  postoperative  vomiting  occurs  the  possibility  that  the  morphia 
used  to  control  pain  and  discomfort  may  be  a  causative  factor  should  be 
considered,  and  if  codeia  combined  with  the  use  of  aspirin  by  rectum 
proves  inadequate,  opium  suppositories  may  prove  effective,  both  in 
relieving  the  pain  and  controlling  the  vomiting. 

Thirst. — Most  patients  complain  of  thirst  after  any  abdominal  opera- 
tion. This  can  be  relieved  to  some  extent  by  the  rectal  adm.inistration 
of  eight  ounces  of  tap  water  every  three  or  four  hours,  tO'  which  may 
be  added  one  drachm  of  bicarbonate  of  soda  as  a  prophylaxis  against 
any  tendency  to  acidosis,  which  is  a  not  uncommon  sequel  of  anesthesia 
and  may  prove  an  annoying  factor  in  causing  postoperative  vomiting. 
Since,  however,  there  is  usually  little  vomiting,  if  the  stomach  has  been 
cleansed  of  any  ether  it  may  contain  by  lavage,  the  patients  may  be  given 
water  by  mouth  in  moderate  amounts  as  soon  as  they  recover  from  the 
immediate  effects  of  the  anesthetic.  If  vomiting  occurs,  water  should  be 
temporarily  withheld.  It  is  unwise  to  give  large  amounts  at  any  one 
time  in  the  first  forty-eight  hours,  owing  to  the  fact  that  large  amounts 
of  liquids  by  mouth  apparently  favor  acute  dilatation  of  the  stomach, 
which  seems  to  be  a  relatively  common  complication  after  cesarean  sec- 
tion, especially  in  patients  who  suffer  severely  from  hyperacidity  and 
other  digestive  disturbances  during  pregnancy,  or  who,  when  not 
pregnant,  show  ptosis  of  the  abdominal  viscera. 

Diet. — It  is  usually  customary  after  an  abdominal  operation  to  begin 
feeding  the  patient  small  amounts  of  liquid  nourishment  as  soon  as  the 
tendency  to  nausea  has  disappeared,  gradually  increasing  the  amount 
and  not  giving  solid  food  until  usually  forty-eight  hours  or  more  have 
elapsed.  My  experience  with  cesarean  section  has  convinced  me  that  a 
copious  supply  of  liquids  by  mouth  shortly  after  operation  tends  to 
increase  the  tendency  to  gastric  dilatation,  and  it  is  now  my  custom 
to  begin  with  small  amounts  of  orange  juice  and  albumen,  or  milk  and 
lime  water,  in  not  more  than  one  ounce  doses  at  hourly  intervals  to  test 
the  tolerance  of  the  stomach.  If  after  two  or  three  doses  the  stomach 
seems  to  be  tolerant  I  then  shift  at  once  to  a  semisolid  diet,  milk  toast, 
junket,  cereals,  etc.,  given  in  small  amounts  at  relatively  frequent  in- 
tervals, and  believe  that  if  the  patient  is  treated  in  this  way  the  danger 
of  acute  dilatation  of  the  stomach  is  much  diminished,  though  not  entirely 
abolished,  since  in  some  patients  general  ptosis  of  the  abdominal  organs 
is  present  and  the  sudden  relief  of  pressure,  incident  to  the  emptying  of 
the  uterus,  allows  the  stomach  to  prolapse,  and  a  kink  being  formed  in 
the  duodenum,  dilatation  of  the  stomach  results.     If  after  the  second 


AFTER  CARE  121 

day  the  stomach  is  functioning  satisfactorily,  the  patient  is  put  on  a  full 
diet,  on  the  theory  that  if  a  full  diet  is  given  as  early  as  possible,  not 
only  will  the  patient  recover  her  normal  strength  more  quickly,  but  that 
lactation  will  be  established  earlier  and  more  satisfactorily. 

Bladder. — Some  authorities  recommend  that  the  cesarean  patient 
should  be  catheterized  about  twelve  hours  after  operation  and  from 
then  on  at  regular  intervals  for  the  next  forty-eight  hours.  I  consider 
this  distinctly  pernicious  teaching  on  account  of  the  danger  of  infection 
of  the  bladder.  There  is  no  reason  for  catheterization  in  the  average 
case  for  practically  twenty-four  hours;  unless  the  patient  complains  of 
discomfort.  The  average  secretion  of  urine  is  not  over  twenty  ounces 
during  this  period,  and  the  great  majority  of  cases  will  be  able  to  urinate 
spontaneously,  if  properly  encouraged,  before  the  bladder  becomes  over- 
distended  or  marked  discomfort  develops.  If  discomfort  develops,  the 
patient  should  be  promptly  relieved,  and  if  repeated  catheterization  is 
found  necessary,  urotropin  gr.  v-x  should  be  given  every  four  hours  as 
a  prophylactic  against  bladder  infection  as  soon  as  the  stomach  is 
tolerant.  It  is  also  a  wise  precaution,  when  catheterization  is  necessary 
for  a  considerable  period  of  time,  to  irrigate  the  bladder  with  2  per 
cent  boric  acid  solution  at  the  time  of  catheterization  once  or  twice  a 
day.  If  the  patient  is  treated  in  this  way,  cystitis  will  prove  a  rare 
complication,  even  though  the  use  of  the  catheter  proves  necessary 
throughout  the  entire  period  of  convalescence.  If  the  patient  is  ab- 
solutely unable  to  void,  routine  catheterization  every  eight  hours  should 
be  instituted,  and  if  in  spite  of  the  precautions  above  noted,  signs  of 
bladder  irritability  develop,  the  instillation  of  one  ounce  of  twenty-five 
per  cent  argyrol  into  the  bladder  will  usually  relieve  the  condition.  If 
after  a  few  days  of  catheterization  the  patient  apparently  regains  control 
of  the  bladder,  the  routine  use  of  the  catheter  should  be  omitted;  but 
since  in  some  cases  the  emptying  of  the  bladder  is  only  partial,  sometimes 
only  the  overflow  from  a  distended  bladder  being  evacuated,  it  is  well  to 
catheterize  once  daily  for  a  day  or  two,  because  if  a  considerable  residual 
quantity  of  urine  remains,  infection  is  very  apt  to  occur  and  a  trouble- 
some cystitis  develop.  This  is  particularly  true  when  catheterization  has 
been  necessary  for  several  days,  and  should  be  guarded  against. 

Bowels. — The  bowels  should  be  opened  rather  more  promptly  after 
cesarean  section  than  after  an  ordinary  laparotomy.  This  is  advisable 
for  two  reasons:  in  the  first  place  there  is  usually  an  accumulation  of 
fecal  matter  in  the  intestines  during  the  latter  part  of  pregnancy,  even 
though  apparently  satisfactory  daily  evacuations  have  taken  place,  and 
the  patient  will  be  rendered  much  more  comfortable  if  the  intestinal 


122  CESAREAN  SECTION 

tract  is  emptied  early  in  the  convalescence.  In  the  second  place  the 
sudden  alteration  in  intra-abdominal  pressure  in  women  who  have  been 
delivered  by  cesarean  section,  plus  the  tendency  to  intestinal  stasis  and 
gas  formation  in  any  patient  who  has  had  an  abdominal  operation,  pre- 
disposes markedly  to  the  accumulation  of  gas  in  the  intestinal  tract. 
In  many  cases  the  distention  is  extreme  and  the  patients  suffer  marked 
discomfort,  the  abdomen  being  so  distended  as  to  be  as  large  as  before 
operation.  In  some  cases,  of  course,  this  distention  is  a  sign  of  peritoneal 
infection  more  or  less  severe,  but  in  the  majority  of  cases  it  is  the  result 
of  natural  mechanical  conditions.  Much  can  be  done  to  lessen  its 
severity,  if  steps  are  taken  early  in  the  convalescence.  A  very  satisfac- 
tory method  of  opening  the  bowels  is  to  give  the  patient  one  half  ounce 
of  milk  of  magnesia  by  mouth  every  four  hours  beginning  as  soon  as  any 
tendency  to  nausea  has  disappeared.  This  has  a  double  advantage  in 
being  a  mild  laxative  and  in  counteracting  the  hyperacidity  of  which 
many  patients  complain  for  the  first  few  days  after  operation.  In 
addition,  the  rectal  tube  is  inserted  at  frequent  intervals,  and  unless  it 
causes  severe  discomfort  it  is  left  in  situ  for  considerable  periods  of 
time,  though  not  constantly,  as  some  operators  advise.  If  signs  of  dis- 
tention occur  early,  or  if  the  patient  begins  to  pass  gas  through  the  tube, 
an  ampul  of  pituitary  extract  is  given  hypodermically.  This  is  followed 
in  from  one  half  to  one  hour  by  an  enema  consisting  of  two  ounces  of 
glycerin  and  two  of  water.  This  is  retained  in  the  rectum  for  about 
two  hours,  unless  it  acts  promptly,  when  it  is  followed  by  an  enema  com- 
posed of  either  milk  and  molasses  in  equal  parts  of  eight  ounces  each, 
or  of  epsom  salts  two  ounces,  glycerin  two  ounces,  and  water  eight 
ounces,  with  two  drachms  of  spirits  of  turpentine. 

Not  infrequently  the  first  enema  will  give  marked  relief,  much  gas 
and  more  or  less  fecal  matter  being  passed,  -but  it  is  often  necessary  to 
give  repeated  enemata,  in  which  case  it  is  well  to  alternate  between 
the  two.  If  the  patient  is  not  in  good  condition  and  the  use  of  an 
enema  causes  marked  exhaustion,  as  is  sometimes  the  case,  the  milk  of 
magnesia,  pituitary  extract  and  the  rectal  tube  will  often  prove  sufficient, 
although  in  a  few  cases  a  stronger  cathartic  may  prove  necessary. 

If  there  is  no  tendency  to  distention  and  if  the  patient  is  not  uncom- 
fortable, it  is  well  to  leave  the  bowels  alone  for  forty-eight  hours,  when 
the  use  of  enemata,  with  or  without  pituitary  extract,  will  prove  promptly 
successful  in  most  cases.  It  is  my  feeling  that  after  ordinary  operations 
most  surgeons  attempt  to  open  the  bowels  unnecessarily  early,  rather  for 
the  purpose  of  relieving  their  own  minds  than  for  the  welfare  of  the 
patient,  and  the  patient  is  often  left  nervously  and  physically  exhausted 


AFTER  CARE  123 

as  the  result  of  too  active  attempts  to  empty  the  lower  bowel,  when  there 
is  little  or  nothing  there  to  be  removed  by  enemata.  After  cesarean  sec- 
tion, however,  the  tendency  to  abdominal  distention  from  purely  me- 
chanical causes  is  so  great  that  it  is  distinctly  advisable  to  open  the 
bowels  early  to  prevent  the  discomfort  incident  to  marked  intestinal 
distention. 

Lochia.— If  the  uterus  and  lower  segment  have  been  emptied  of  clots 
at  the  time  of  operation,  the  flowing  will  be  no  more  profuse,  and  in 
many  cases  distinctly  less  profuse,  then  after  a  normal  labor.  If,  how- 
ever, the  lower  uterine  segment  has  been  left  filled  with  clots  at  the 
end  of  operation,  these  clots  must  come  away,  and  until  the  accumulation 
is  evacuated  the  flowing  will  be  more  profuse  than  normal,  and  clots 
of  considerable  size  may  be  passed. 

It  not  infrequently  happens,  however,  that  retention  of  lochia  occurs 
to  a  considerable  degree  just  as  after  normal  labor,  becoming  evident 
usually  about  the  third  or  fourth  day.  This  is  theoretically  more  likely 
to  happen  when  the  operation  has  been  performed  on  patients  at  the 
time  of  election,  before  any  dilatation  of  the  cervix  has  taken  place,  but 
in  my  experience  cervical  dilatation  seems  to  make  little  difference,  and 
I  have  seen  a  number  of  cases  of  retention  of  lochia  in  patients  who  were 
well  advanced  in  labor  at  the  time  of  operation.  Placing  the  patient 
in  Fowler's  position  to  favor  drainage,  an  ice  bag  over  the  uterus  to 
stimulate  contraction,  and  the  administration  of  small  doses  of  fluid 
extract  of  ergot  by  mouth  (unless  it  causes  nausea)  will  usually  prove 
promptly  successful  in  relieving  the  retention.  If  these  measures  do  not 
succeed  promptly,  and  especially  if  the  patient  begins  to  have  an  eleva- 
tion of  temperature  and  show  other  signs  of  absorption  from  the  uterus, 
more  active  measures  should  be  resorted  to. 

In  some  instances  the  retention  is  due  to  the  non-dilatation  of  the 
cervix,  or  to  its  recontraction,  if  it  was  dilated  at  the  time  of  operation, 
but  in  others  it  seems  to  be  due  to  the  exaggerated  angle  between  the 
cervix  and  body  of  the  uterus,  which  is  commonly  seen  in  normal  labor. 
To  secure  proper  drainage  in  these  cases  the  cervix  should  be  freely 
dilated  with  a  steel  dilator.  Even  in  patients  who  were  not  in  labor 
when  cesarean  section  is  performed  the  cervix  will  be  found  so  much 
softened  and  relaxed  by  the  end  of  forty-eight  hours  that  little  force  is 
necessary  to  dilate  it,  and  the  procedure  usually  causes  so  little  pain  that 
the  use  of  an  anesthetic  is  seldom  called  for,  although  any  manipulation 
of  the  uterus  produces  more  or  less  discomfort. 

Strict  surgical  asepsis  must  be  carried  out.  The  patient  is  placed  in 
the  cross  bed  position,  or  on  a  table,  if  a  good  light  cannot  be  obtained 


124  CESAREAN  SECTION 

in  bed.  The  vagina  is  thoroughly  cleansed.  The  cervix  is  exposed  by  a 
speculum,  grasped  with  bullet  forceps  and  drawn  down  as  close  to  the 
vulval  outlet  as  is  possible  without  causing  too  much  pain,  and  then  care- 
fully cleansed  with  alcohol.  It  is  now  freely  dilated  with  a  branched 
dilator  up  to  the  point  at  which  it  will  admit  one  or  two  fingers  freely. 
A  small  amount  of  lochia  and  perhaps  a  few  clots  will  escape  from 
the  uterus,  but  usually  a  very  small  amount  when  it  is  compared  with 
the  degree  of  comfort  the  patient  experiences  from  the  relief  of  the 
retention.  The  important  faqtor  seems  to  be  the  establishment  of  free 
drainage,  rather  than  the  amount  of  retained  lochia  removed.  Curettage 
under  these  conditions  is  distinctly  not  to  be  advised,  the  removal  of 
the  obstruction  to  drainage  being  all  that  is  necessary. 

Antiseptic  Precautions. — The  same  antiseptic  precautions  should  be 
adhered  to  after  cesarean  section  as  after  normal  delivery.  If  the  vulva 
is  not  kept  cleansed  from  lochia,  decomposition  will  occur  and  the  un- 
pleasant odor  will  keep  the  patient  uncomfortable.  I  do  not  believe  that 
an  ascending  infection  will  result  from  this  lack  of  cleanliness,  but  a 
nurse  who  does  not  keep  her  patient  clean  is  not  to  be  trusted  in  other 
respects.  The  vulva  should  be  kept  covered  with  a  sterile  pad,  which 
should  be  changed  as  a  routine  every  three  or  four  hours,  or  whenever 
soaked  with  lochia.  It  should  also  be  changed  after  urination  or 
defecation.  Whenever  the  pad  is  changed  the  vulva  should  be  douched 
ofif  with  a  non-irritating  sterile  solution.  Boric  acid  or  sterile  water  is 
satisfactory  for  the  purpose.  Corrosive  sublimate  should  not  be  used, 
even  in  a  weak  solution,  since  it  can  accomplish  no  useful  purpose 
as  an  antiseptic  and  not  infrequently  a  dermatitis  results  from  its  use, 
which  adds  greatly  to  the  patient's  discomfort. 

The  use  of  vaginal  douches  during  the  early  part  of  the  puerperium 
should  not  be  permitted  under  any  circumstances.  In  the  first  place  they 
accomplish  nothing,  and  in  the  second  they  may  be  productive  of  harm, 
if  improperly  given.  After  the  end  of  a  week  a  sterile  vaginal  douche 
may  be  given  daily,  if  the  lochia  have  an  offensive  odor,  and  later  in  the 
puerperium  douches  may  be  used,  if  the  uterus  is  not  involuting  properly, 
but  in  the  routine  care  of  the  convalescence  they  have  no  place. 

Lactation  and  Nursing. — It  has  seemed  to  me  that  patients  who 
have  been  delivered  by  cesarean  section  are  on  the  whole  less  likely  to 
be  able  to  nurse  than  women  delivered  normally,  and  that  even  if  they 
eventually  do  make  satisfactory  wet  nurses,  the  establishment  of  lactation 
is  delayed  for  from  one  to  three  days  longer  than  in  the  average  normal 
patient.  This  may  be  accounted  for  in  elderly  primiparae  on  the  theory 
of  the  atrophy  of  disuse,  the  breasts  having  gone  so  long  without  being 


AFTER  CARE  125 

called  on  to  function  that  degenerative  changes  have  taken  place  in  the 
glands. 

In  women  with  undeveloped  pelves,  i.e.,  justominor  pelves,  the 
pelvic  organs  are  apt  to  be  underdeveloped  as  well  as  the  pelvis.  It  is 
very  probable  that  the  mammary  glands  are  somewhat  undeveloped 
also  and  are,  therefore,  in  such  women  less  likely  to  function  properly, 
a  fact  which  probably  often  accounts  for  the  patient's  inability  to  nurse 
her  child.  In  other  cases,  as  for  instance  in  subnormal  women  who  are 
delivered  by  cesarean  section  in  preference  to  a  pelvic  delivery,  the  reason 
for  unsatisfactory  lactation  is  evident,  since  these  women  are  seldom 
good  wet  nurses  after  a  normal  delivery.  In  many  cases,  however,  no 
explanation  for  the  unsatisfactory  breast  function  is  evident,  although 
the  delay  may  be  due,  at  least  in  part,  to  the  period  of  starvation  which 
follows  operation. 

Since  these  classes  of  patients  make  up  a  very  considerable  propor- 
tion of  the  patients  for  whom  I  consider  cesarean  section  advisable  in 
private  practice,  the  explanation  of  what  is  definitely  true  in  my  ex- 
perience, that  cesarean  patients  are  less  likely  to  prove  satisfactory  wet 
nurses  than  women  delivered  normally,  may  be  merely  the  type  of 
women  on  whom  the  operation  is  performed,  rather  than  the  method 
of  delivery. 

Temperature. — Patients  who  have  undergone  cesarean  section  seem 
to  be  more  prone  to  have  an  elevation  of  temperature  than  patients 
who  have  had  other  abdominal  operations.  Aside  from  the  patients  in 
whom  definite  infection  is  diagnosed  or  suspected,  or  in  whom  retention 
of  lochia  occurs,  various  minor  conditions  cause  an  undue  reaction,  a 
fact  which  is  to  a  certain  degree  noticeable  in  women  after  normal  labor. 
This  is  probably  to  be  explained  by  the  fact  that  absorption  from  the 
extensive  wound  surface,  plus  the  waste  products  produced  by  the 
involution  of  the  uterus,  tax  the  excretory  organs  tO'  the  limit  and  render 
the  patient  unduly  susceptible  to  minor  stimuli.  Furthermore,  in  the 
closing  of  the  uterine  wound  a  large  amount  of  suture  material  is  buried, 
and  it  is  also  probable  that  a  certain  amount  of  pressure  necrosis  develops 
around  the  sutures,  particularly  if  they  are  tied  too  tightly  in  the  at- 
tempt to  control  all  hemorrhage,  both  of  which  factors  increase  the 
absorption  and  render  the  patient  more  susceptible  to  minor  disturbances 
of  function  which  under  normal  conditions  would  not  give  a  noticeable 
reaction. 

Immediately  following  operation  there  is  apt  to  be  a  moderate  rise 
of  temperature,  as  a  rule  not  over  100.5  degrees,  but  occasionally  reach- 
ing loi  or  102  degrees.     In  clean  cases  the  temperature  reaches  normal 


126  CESAREAN  SECTION 

in  from  twenty-four  to  forty-eight  hours  and  should  remain  at  ap- 
proximately the  normal  level  throughout  the  remainder  of  the  con- 
valescence, but  any  complication  which  arises  will  be  attended  by  a  rise 
in  temperature.  This  initial  temperature  may  be  due  to  a  slight  peri- 
toneal reaction  caused  by  the  spilling  of  more  or  less  liquor  amnii  into 
the  abdominal  cavity  when  the  uterus  is  opened.  It  is  unimportant  in 
itself,  but  shows  what  may  be  expected,  if  in  infected  cases  any  of  the 
infected  liquor  escapes  into  the  peritoneal  cavity. 

Any  cause  which  would  lead  to  a  rise  in  temperature  after  a  normal 
delivery  will  cause  a  similar  reaction  after  cesarean  section,  but  in  most 
cases  the  uterus  will  be  the  offending  organ. 

Pulse. — The  pulse  after  cesarean  section  shows  nothing  remarkable. 
It  is  apt  to  be  very  rapid  during  operation,  and  at  the  time  when  the 
uterus  is  opened  the  pulse  may  temporarily  disappear.  This  should  cause 
no  anxiety,  however,  as  it  seems  to  be  entirely  without  significance.  Dur- 
ing closure  of  the  uterus  the  pulse  usually  improves  in  quality  and  be- 
comes slower,  to  again  become  more  rapid  when  the  patient  begins  to 
come  out  of  ether.  The  pulse  rate  then  drops  to  or  even  below  normal 
in  patients  who  have  not  suffered  severely  from  hemorrhage  or  ex- 
haustion, just  as  in  the  normal  obstetric  case.  A  rising  pulse  within  a 
few  hours  after  delivery  may  be  a  suggestion  of  internal  concealed 
hemorrhage  and  should  call  for  investigation. 

A  sharp  rise  in  the  pulse  rate  may  occur  in  the  second  twenty-four 
hours,  the  rate  sometimes  reaching  130-140.  This  is  often  an  accompani- 
ment of  acute  dilatation  of  the  stomach,  and  indeed  a  rapidly  rising 
pulse  may  be  the  first  noticeable  symptom  of  this  complication  and 
should  be  taken  as  a  danger  signal.  With  marked  intestinal  distention 
the  pulse  will  usually  be  rapid,  but  in  these  cases  the  change  will  be 
gradual  and  not  as  sudden  as  in  dilatation  of  the  stomach.  In  other 
complications  the  pulse  rate  follows  the  temperature  fluctuations  more 
or  less  closely,  except  that  in  cases  of  general  peritonitis  a  rising  pulse  will 
often  be  associated  with  a  dropping  temperature  in  the  terminal  stages. 

As  a  general  rule  a  dropping  pulse  is  a  favorable  sign  in  cases  of 
infection,  even  though  the  temperature  remains  high,  and  a  favorable 
prognosis  can  be  given  in  such  cases,  since  the  temperature  will  follow 
the  pulse  within  a  day  or  two,  the  improvement  in  the  pulse  rate  being 
an  index  of  the  increased  resistance  of  the  patient. 

LTTEEATUEE 

III,  C.  L.     The  Alcohol  Drain  in  Septic  Cases  Requiring  Cesarean  Sec- 
tion.   Am.  Jr.  Obst.     1918.    yy  \  i. 


CHAPTER  X 

COMPLICATIONS  OF  THE  CONVALESCENCE 

Acute  Dilatation  of  Stomach — Pneumonia — Embolism — Septic  Complications — Infec- 
tion of  Uterine  Wound — Cystitis — Thrombophlebitis — Peritonitis — Appendicitis — 
Bibliography, 

The  convalescence  from  cesarean  section  may  be  expected  to  be  a 
fairly  smooth  one  in  the  majority  of  patients  in  whom  the  operation 
is  elective,  but  any  of  the  complications  which  occur  after  normal 
delivery  or  after  laparotomy  may  arise,  and  certain  ones,  e.g.,  retention 
of  lochia  and  acute  dilatation  of  the  stomach,  are  relatively  common. 
The  convalescence  following  operation  on  doubtful  risks  is  apt  to  be 
a  very  stormy  one,  however,  and  many  patients  only  recover  after  a 
prolonged  and  desperate  illness,  while  the  mortality  in  these  patients  is 
relatively  high. 

Acute  Dilatation  of  the  Stomach. — Perhaps  the  most  common,  as 
well  as  the  earliest  complication  to  be  looked  for,  following  cesarean 
section,  is  acute  dilatation  of  the  stomach.  It  occurs  much  more  fre- 
quently apparently  after  this  operation  than  after  any  other  laparotomy, 
and  is  more  liable  to  affect  certain  types  of  patients  than  others,  being 
met  with  much  more  often  in  private  than  in  hospital  practice. 

Patients  suffering  from  ptosis  of  the  abdominal  viscera  before  the 
beginning  of  pregnancy  seem  to  be  more  apt  to  develop  this  compHcation 
than  other  types  of  patients.  This  is  probably  due  to  the  fact  that  the 
stomach,  which  has  been  held  up  in  good  position  by  the  enlarged  uterus, 
prolapses  as  soon  as  the  support  is  removed.  In  its  new  position  a  kink 
is  formed  at  or  near  the  pylorus  and  drainage  is  interfered  with  to  such 
an  extent  that  it  becomes  acutely  distended.  That  acute  dilatation  is 
not  more  common  after  normal  delivery  suggests  that  some  other  factor 
than  ptosis  must  be  present,  and  this  factor  is  probably  supplied  by  the 
increased  gas  formation  and  diminished  peristalsis,  which  so  often  fol- 
low abdominal  operations,  a  more  or  less  sharp  angle  at  the  pyloric  end 
of  the  stomach  being  closed  by  the  pressure  of  the  distended  intestine 
below.  The  condition  seems  also  to  be  favored  by  the  ingestion  of  large 
amounts  of  fluid  in  the  first  thirty-six  hours  after  operation,  and  ap- 
parently occurs  less  often  if  the  patients  are  given  water  rather  sparingly 
and  are  on  a  semisolid  diet  from  the  beginning. 

127 


128  CESAREAN  SECTION 

Another  class  of  patients  who  seem  particularly  liable  to  this  com- 
plication are  the  neurotic  women  who  suffer  markedly  from  hyperacidity 
and  other  digestive  disorders  during  pregnancy.  There  may  be  a  ten- 
dency to  ptosis  in  these  women  also,  but  in  many  cases  at  least  it  is  not 
demonstrable  until  after  delivery,  and  has  not  been  discovered  in  the 
non-pregnant  condition. 

The  relative  frequency  of  gastric  dilatation  in  private,  as  compared 
with  hospital  practice,  would  seem  to  be  due  to  the  fact  that  in  private 
practice  the  operation  is  often  performed  because  the  patient  seems  a 
poor  general  risk  for  the  strain  of  labor,  rather  than  for  pelvic  insuffi- 
ciency, a  fact  which  only  enters  into  hospital  practice  to  a  limited  degree. 
There  seems  to  be  no  doubt  but  that  the  high  incision  predisposes  to  this 
complication  to  some  extent,  but  the  general  condition  of  the  patient 
seems  to  be  even  more  of  a  factor  in  its  production. 

In  typical  cases  the  patient  seems  in  good  condition  shortly  after 
operation.  The  temperature  may  be  slightly  elevated,  99°-! 00°  or 
practically  normal  at  the  end  of  twenty-four  hours,  and  the  pulse  is 
normal.  There  is  no  nausea  and  the  patient  seems  to  be  doing  well. 
Some  time  during  the  next  twelve  to  twenty-four  hours  the  patient's 
condition  changes  markedly  for  the  worse.  Nausea  develops,  attended 
by  hiccough  in  many  cases,  and  the  patient  may  begin  to  spit  up  small 
quantities  of  a  dark  greenish  fluid  with  an  unpleasant  odor,  or  she  may 
vomit  a  large  amount  of  the  same  material  with  a  good  deal  of  gas. 
After  a  few  hours  she  begins  to  look  badly  and  the  face  becomes  grayish 
and  drawn.  The  temperature  rises  in  some  cases  to  101°  or  102°,  and 
the  pulse  becomes  progressively  more  rapid,  at  times  reaching  140  or 
more  within  a  few  hours,  and  the  quality  changes  for  the  worse.  The 
picture  often  looks  like  that  seen  in  a  beginning  peritonitis.  The  abdomen 
is  distended,  particularly  in  the  upper  portion,  but  the  distention  is  soft 
and  the  abdomen  is  usually  not  unduly  tender.  At  times  the  patient  ap- 
pears seriously  sick,  and  she  is  always  restless  and  uncomfortable.  This 
sudden  change  from  being  in  satisfactory  condition  to  being  apparently 
a  very  sick  woman  suggests  one  of  two  things,  either  peritoneal  in- 
fection, due  to  a  very  virulent  organism,  in  which  case  the  prognosis 
is  hopeless,  or  acute  dilatation  of  the  stomach.  In  most  cases  it  is  the 
latter  and  the  means  of  diagnosis  and  treatment  are  the  same,  i.e.,  gastric 
lavage.  The  passage  of  the  stomach  tube  is  often  followed  by  the  ex- 
plosive escape  of  gas  through  the  tube,  followed  by  a  large  amount, 
often  a  pint  or  more,  of  the  same  sort  of  material  that  the  patient  has 
been  regurgitating.  The  stomach  should  be  washed  out  with  warm  water 
containing  bicarbonate  of  soda  and  then  drained  and  left  empty.     The 


COMPLICATIONS  OF  THE  CONVALESCENCE  129 

patient  should  then  be  given  an  injection  of  1/6  gr.  of  morphia  to  quiet 
her  and  give  her  a  chance  to  sleep.  She  should  be  made  to  lie  on  the 
right  side  as  much  of  the  time  as  possible  to  favor  drainage  of  the 
stomach. 

Everything  should  be  withheld  by  mouth  for  several  hours.  If  the 
patient  is  uncomfortable  from  thirst,  or  if  the  tissues  seem  dried  out, 
the  mouth  should  be  swabbed  out  with  water,  and  fluid  should  be  given 
under  the  skin  or  by  rectum.  After  five  or  six  hours  food  may  be  given, 
preferably  of  the  semisolid  variety,  in  small  amounts.  The  improve- 
ment in  the  patient's  condition  under  this  form  of  treatment  is  very 
rapid,  the  pulse  and  temperature  dropping  quickly  to  normal,  unless  the 
condition  has  persisted  some  time  before  being  treated.  Occasionally 
the  condition  may  recur  and  a  second  lavage  be  necessary,  but  this  is 
the  exception,  and  one  treatment  is  usually  sufficient,  the  only  after 
effect  being  an  apparent  delay  in  the  establishment  of  lactation,  which 
seems  particularly  late  in  these  cases,  and  is  probably  due  to  the  rather 
prolonged  period  of  starvation  to  which  the  patient  is  subjected.  Whether 
an  uncomplicated  acute  gastric  dilatation  would  ever  prove  fatal  is  a 
question.  The  majority  of  fatal  cases  who  have  come  to  autopsy  have 
shown  either  a  beginning  peritonitis  or  intestinal  obstruction,  but  the 
symptoms  are  often  sufficiently  alarming  to  suggest  the  possibility  of  a 
fatal  issue  unless  relief  is  given,  and  the  results  of  lavage  are  prompt 
and  satisfactory. 

Pneumonia. — So-called  ether  pneumonia  occasionally  occurs  after 
cesarean  section,  but  with  no  greater  frequency  than  after  other  surgical 
operations,  except  perhaps  in  cases  who  have  been  operated  on  as 
emergency  cases  after  having  been  in  labor  for  some  time  and  who 
have  had  no  proper  preparation.  It  is  not  uncommon,  in  my  experience, 
to  find  that  labor  not  infrequently  interferes  with  digestion  and  that 
the  stomach  after  labor  often  contains  undigested  food,  though  no  solid 
food  has  been  taken  for  ten  or  twelve  hours,  or  even  longer.  Inhalation 
pneumonia  is  not  an  uncommon  sequel  to  vomiting  under  the  anesthetic 
in  patients  of  this  type. 

The  treatment  is  symptomatic  and  the  course  is  usually  short  and 
favorable.  A  certain  number  of  the  patients  die,  however,  and  pneu- 
monia must  be  considered  as  one  of  the  dangers  attendant  on  surgery 
under  general  anesthesia,  especially  on  patients  who  have  not  been 
properly  prepared  for  operation.  Within  the  last  few  years  it  has  been 
suggested  that  the  so-called  ether  pneumonia  is  not  dependent  on  the 
anesthetic,  but  occurs  with  practically  equal  frequency  after  abdominal 
operations,  performed  under  local  or  spinal  anesthesia,  and  at  least  one 


130  CESAREAN  SECTION 

series  of  cases  has  been  reported  to  support  this  claim.  In  these  cases  the 
pneumonia  must  be  emboHc  in  character  and  not  due  to  irritation  from 
the  anesthetic.     This  has,  however,  not  been  my  own  experience. 

Embolism. — In  comparatively  rare  instances,  very  rare  if  we  except 
the  cases  secondary  to  pelvic  thrombophlebitis,  pulmonary  embolism  oc- 
curs with  serious  or  fatal  results.  There  are  no  means  of  predicting 
when  it  will  occur  and  no  means  of  preventing  its  occurrence.  It  is 
simply  one  of  the  surgical  accidents  which  may  follow  any  case  of  labor 
or  abdominal  operation,  but  particularly  operations  on  the  uterus,  and 
its  possibility  must  be  considered  in  stating  the  prognosis  of  the  operation 
to  the  patient.  It  is  probably  slightly  more  common  after  cesarean 
section  than  after  normal  labor,  but  this  is  probably  due  to  the  fact 
that  phlebitis  is  rather  more  common  in  these  cases,  owing  tO'  the  fact 
that  many  operations  are  performed  on  patients  who  are  already  infected 
with  organisms  of  low  virulence  by  vaginal  interference  at  the  time 
operation  is  undertaken.  Embolism  may  occur  at  any  time  after  opera- 
tion, just  as  after  normal  labor,  growing  progressively  less  frequent  the 
longer  the  interval  since  operation  in  normal  cases.  In  septic  cases  with 
thrombophlebitis  embolism  usually  occurs  late  in  the  convalescence,  i.e., 
between  the  second  and  fourth  weeks  as  a  rule,  and  the  patient  cannot 
be  considered  out  of  danger  until  sufficient  time  has  elapsed  for  com- 
plete organization  of  the  thrombus  to  take  place. 

Septic  Complications. — One  of  the  most  common  septic  complica- 
tions following  cesarean  section  is  a  thrombophlebitis  of  the  pelvic 
veins,  which  may  involve  the  veins  of  one  or  both  legs  by  extension  and 
give  rise  to  phlegmasia  alba  dolens.  The  general  consensus  of  opinion 
is  that  phlebitis  is  secondary  to  a  septic  process  at  the  site  of  operation. 

As  is  to  be  expected,  therefore,  phlebitis  is  most  common  in  the 
patients  on  whom  cesarean  section  is  performed  under  relatively  un- 
favorable conditions,  i.e.,  after  prolonged  labor  or  after  repeated  vaginal 
examinations  or  attempts  at  delivery.  The  uterine  wound  in  these  cases 
is  prone  to  become  infected  and  a  septic  thrombosis  of  the  pelvic  veins 
results.  In  other  cases,  when  the  uterine  sutures  have  been  tied  too 
tightly,  a  certain  amount  of  pressure  necrosis  results.  If  no  infective 
agent  is  present  the  necrotic  tisue  will  be  taken  care  of  without  symptoms, 
but  in  a  large  proportion  of  cases  a  culture  from  the  fundus  of  the 
uterus  will  show  pyogenic  organisms  by  the  end  of  the  week  or  ten  days 
after  delivery,  even  though  no  vaginal  interference  has  been  practiced, 
as  has  been  repeatedly  demonstrated  in  cases  delivered  normally.  If  the 
sutures  used  in  closing  the  uterine  incision  enter  the  uterine  cavity  thes^ 


COMPLICATIONS  OF  THE  CONVALESCENCE  131 

necrotic  areas  may  become  sufficiently  infected  to  form  a  septic  focus 
from  which  phlebitis  may  result. 

In  still  other  cases  a  septic  cystitis,  due  to  unclean  catheterization, 
may  be  the  focus  of  infection  which  results  in  phlebitis.  In  other  words 
any  septic  focus  in  or  near  the  uterus  may  act  as  the  exciting  cause.  I 
am  extremely  skeptical  in  regard  to  the  occurrence  of  phlebitis  in  the 
absence  of  sepsis,  except  in  the  very  rare  cases  which  occur  so  soon  after 
delivery  that  only  a  preexisting  sepsis  might  have  caused  them,  and  even 
in  these  cases  a  septic  focus  elsewhere  in  the  body  cannot  be  eliminated 
as  a  possible  cause. 

As  a  rule,  in  the  patients  who  develop  phlebitis,  the  convalescence 
has  not  been  normal.  The  pulse  and  temperature  have  usually  been 
suggestive  of  the  fact  that  some  septic  absorption  was  going  on,  although 
the  symptoms  may  not  have  been  severe  enough  for  definite  localization. 
Usually  the  definite  symptoms  appear  at  or  near  the  end  of  the  second 
week,  pain  and  tenderness  in  the  groin  with  swelling  of  the  leg  and  a 
rise  of  pulse  and  temperature. 

The  treatment  of  these  cases  consist  of  absolute  rest  and  the  relief 
of  pain.  The  affected  leg  should  be  placed  at  once  in  a  pillow  splint, 
partly  for  comfort,  but  more  to  prevent  the  patient  from  moving  it 
thoughtlessly,  and  thus  favoring  the  detachment  of  a  portion  of  the 
occluding  thrombus  and  embolism.  An  ice  bag  applied  over  the  groan, 
lead  and  opium  liniment  along  the  course  of  the  affected  veins,  and  the 
use  of  aspirin  will  usually  control  the  pain,  though  in  some  cases  opiates 
may  be  necessary  for  a  few  days.  Fresh  air,  sunlight  and  good  food, 
to  raise  the  patient's  general  condition,  should  form  a  part  of  the  treat- 
ment. 

It  is  always  a  question  whether  anything  can  be  done  to  limit  the 
extension  of  or  to  favor  the  resolution  of  the  thrombi  in  the  affected 
veins.  For  several  years  I  have  employed  lemon  juice,  or  citric  acid  in 
capsules,  in  the  treatment  of  all  cases  of  phlebitis,  or  as  a  prophylactic 
measure  in  cases  whose  convalescence  was  not  perfectly  normal,  on  the 
theory  that  although  the  pelvic  phlebitis  might  occur  when  a  septic  proc- 
ess was  present  in  the  uterus,  the  extension  of  the  process  into  the  veins 
of  the  legs  might  be  prevented  or  limited  by  lowering  the  clotting  power 
of  the  blood  by  neutralization  of  its  calcium  content. 

The  approximate  dosage  is  forty-five  grains  of  citric  acid  per  day 
for  an  average  sized  person,  or  a  corresponding  amount  of  lemon  juice. 
Although  it  is  impossible  to  state  definitely  whether  any  good  is  ac- 
complished by  this  method  of  treatment  or  not,  I  am  convinced  in  my 
own  mind  that  such  cases  of  phlebitis  as  I  see  are  milder  in  course  and 


132  CESAREAN  SECTION 

leave  less  permanent  disability  than  before  I  began  the  use  of  citric  acid. 
It  may  be,  of  course,  that  the  cases  have  all  been  mild,  and  that  the 
veins  of  the  legs  would  not  have  been  seriously  involved  in  the  process 
in  any  case,  but  the  general  results  of  my  experience  would  seem  to 
show  that  citric  acid  has  a  distinctly  favorable  action  in  these  cases. 

The  great  danger  to  the  life  of  the  patient  in  septic  thrombophlebitis 
is  pulmonary  embolism,  and  embolism  is  distinctly  favored  by  pre- 
mature motion  of  the  affected  limb  before  organization  of  the  clot  is 
complete.  It  is,  therefore,  necessary  to  keep  the  patient  at  rest  until 
complete  organization  of  the  thrombi  must  have  taken  place  under  all 
ordinary  conditions,  and  then  for  a  week  longer  to  be  absolutely  on  the 
safe  side.  It  is  generally  fair  to  assume  that  after  the  temperature  has 
been  normal  for  at  least  a  week  and  the  swelling  of  the  leg  has  prac- 
tically subsided,  and  also  the  pain  has  entirely  disappeared,  that  the 
danger  of  embolism  is  over,  and  the  addition  of  a  week's  rest  makes 
assurance  doubly  sure.  In  these  cases,  although  the  patient  is  usually 
very  impatient  to  be  up  and  about  after  her  long  confinement  to  bed,  I 
find  that  a  frank  statement  of  the  facts  never  fails  to  have  the  desired 
result  and  the  patient  is  willing  to  remain  at  rest  as  long  as  seems  best, 
even  though  it  may  not  be  necessary. 

Abscess  of  the  Uterine  Wall. — Infection  of  the  uterine  wall  with 
abscess  formation  is  a  not  infrequent  complication  of  cesarean  section 
performed  on  patients  who  have  been  exposed  to  infection  prior  to  the 
operation.  It  is  particularly  liable  to  occur  when  the  uterine  incision 
is  so  sutured  that  the  endometrium  as  well  as  the  musculature  is  included 
in  the  sutures. 

The  symptoms  are  slow  in  developing  as  a  rule,  unless  the  infective 
agent  is  a  virulent  streptococcus.  The  symptoms  in  the  main  are  per- 
sistent elevation  of  the  pulse  and  temperature,  increased  leukocytosis, 
moderate  abdominal  distention  suggestive  of  pelvic  peritonitis,  and 
marked  tenderness  of  the  uterus.  The  outcome  largely  depends  on  the 
organism  which  causes  the  infection  and  the  efficiency  of  the  peritoneal 
suture.  If  the  organism  which  causes  the  infection  is  a  virulent  strepto- 
coccus, extension  to  the  peritoneum,  or'  infection  of  the  blood  current  is 
probable.  If  the  organism  is  a  staphylococcus  or  the  colon  bacillus, 
local  pus  formation  is  the  rule,  and  the  outcome,  unless  the  abscess  is 
drained,  depends  on  the  efficiency  of  the  uterine  suture.  If  the  peritoneal 
suture  has  been  carefully  done  and  is  well  healed,  the  abscess  will  prob- 
ably eventually  point  into  the  uterine  cavity  after  the  catgut  sutures  are 
absorbed,  and  the  patient  will  recover  after  discharging  a  considerable 
amount  of  pus  through  the  cervix.     If  the  abscess  formation  is  close 


COMPLICATIONS  OF  THE  CONVALESCENCE  133 

to  the  peritoneum,  or  if  the  peritoneum  has  not  been  carefully  sutured, 
the  abscess  will  point  intO'  the  peritoneal  cavity.  Unless  the  condition 
is  appreciated  in  such  cases  and  the  abscess  drained,  rupture  into  the 
peritoneal  cavity  will  take  place,  and  the  patient  die  of  peritonitis,  unless 
operative  relief  is  promptly  given,  and  probably  even  then.  This  is 
presumably  what  takes  place  in  the  patients  who  are  running-  a  septic 
temperature  and  pulse  with  moderate  distention,  but  with  no  abdominal 
tenderness  except  over  the  uterus.  The  patient  seems  only  moderately 
sick,  there  is  no  vomiting,  the  bowels  can  be  moved  readily  and  no 
definite  evidence  of  peritoneal  involvement  can  be  made  out,  until  the 
patient  is  seized  with  sudden  sharp  abdominal  pain  and  goes  into  collapse, 
the  pulse  becoming  weak  and  thready  and  even  disappearing.  Prompt 
operation  and  drainage  in  these  cases  may  save  the  patient  even  then, 
but  by  the  time  the  surgeon  sees  the  patient  her  condition  is  usually 
such  that  interference  is  manifestly  hopeless,  and  she  dies  within  a  few 
hours. 

Early  recognition  of  the  condition  and  operation  with  drainage  is 
the  indicated  treatment,  if  the  primary  operation  has  been  done  through 
a  high  incision.  If,  however,  the  operation  has  been  done  through  a 
low  incision,  as  I  believe  is  wise  in  all  cases  in  which  there  is  suspicion 
but  not  proof  of  antepartum  infection,  the  uterus  will  become  adherent 
to  the  abdominal  wound  in  most  cases  and  drain  through  it  without  in- 
fecting the  general  peritoneum. 

In  other  cases  the  abscess  is  deep  in  the  uterine  wall  and  does  not 
burrow  in  either  direction.  These  patients  run  a  septic  chart  and 
gradually  lose  ground  as  time  goes  on,  dying  eventually  from  the 
exhaustion  of  long  continued  sepsis  or  from  a  general  septicemia,  unless 
the  uterus  is  opened  and  drained.  In  these  cases  the  uterus  should  be 
either  removed,  or  what  is  preferable,  sutured  to  the  incision,  incised, 
and  left  open  to  be  closed  at  a  subsequent  operation.  In  all  of  these 
patients  a  weak  scar  will  remain  in  the  uterus,  which  is  very  liable  to 
rupture,  if  in  subsequent  pregnancies  the  patient  is  allowed  to  gO'  into 
labor,  and  may  even  rupture  during  pregnancy,  a  fact  which  must  be 
borne  in  mind  in  all  patients  who^  have  had  repeated  sections  for  delivery. 
A  febrile  convalescence  after  cesarean  section  should  be  regarded  as 
being  possibly  due  to  infection  of  the  uterine  incision,  or  as  indicating  a 
poor  healing  of  the  uterus  with  danger  of  rupture  in  case  of  future 
pregnancies.  In  these  cases,  at  least,  the  policy  of  "once  a  cesarean 
section  always  a  cesarean  section"  is  the  proper  course  to  pursue,  and 
the  operation  should  be  performed  preferably  before  labor  begins,  and 
in  any  case  before  hard  contractions  have  appeared,  in  order  to  reduce 


134  CESAREAN  SECTION 

the  danger  of  uterine  rupture  to  a  minimum.  There  will  always  be  in 
such  patients  a  slight  danger  that  the  scar  will  rupture  during  pregnancy 
and  the  patients  should  be  carefully  watched  throughout  with  this  possi- 
bility in  mind. 

Septic  Peritonitis. — Infection  of  the  peritoneal  cavity  is  a  constant 
menace  in  all  abdominal  operations.  With  the  improved  aseptic  technic 
of  modern  surgery  this  danger  is  reduced  to  a  minimum,  but  even  with 
the  utmost  precautions  a  slip  in  technic  may  occur  and  pass  unnoticed 
with  fatal  results  to  the  patient,  and  if  the  operative  technic  is  any  but 
the  best  the  danger  of  infection  is  greatly  increased.  In  clean  abdominal 
surgery  this  risk  is  a  slight  one,  but  cases  of  infection  occasionally  occur 
in  the  practice  of  the  most  careful  operators,  and,  therefore,  the  risk  must 
be  considered  as  always  present  when  the  prognosis  of  operation  is  under 
discussion,  and  the  utmost  care  taken  to  guard  against  it. 

In  cesarean  section  it  is  possible  for  peritoneal  infection  to  occur  from 
four  different  sources,  which  must  be  recognized  and  guarded  against 
as  far  as  possible :  ( i )  Direct  infection  of  the  peritoneal  cavity  by  faulty 
technic  at  the  time  of  operation  is  always  possible,  but  should  be  exceed- 
ingly rare  if  the  operation  is  performed  by  a  competent  operator  with  a 
well  trained  team  of  assistants  in  a  properly  equipped  hospital.  (2)  In- 
fection of  the  uterus  may  be  present  at  the  time  of  operation  as  a  result 
of  manipulations  by  the  attendant,  or  from  extension  upward  from  the 
vagina  in  cases  long  in  labor,  especially  when  the  membranes  have  been 
ruptured  for  many  hours,  and  peritoneal  infection  may  result  from 
the  escape  of  infected  material  into  the  peritoneal  cavity  when  the  uterus 
is  opened.  (3)  In  a  third  group  of  patients  the  peritoneal  infection 
develops  so  late  in  the  convalescence  that  it  seems  fair  to  assume  that  the 
operation  and  the  uterus  at  the  time  of  operation  were  both  aseptic,  but 
that  the  vaginal  secretions  contained  the  offending  organisms  and  that 
an  ascending  infection  followed  operation,  the  uterine  wound  being  first 
involved  and  later  the  peritoneum  either  by  direct  extension  or  by  rupture 
of  an  abscess  of  the  uterine  wall  into  the  peritoneal  cavity.  It  is  im- 
possible to  tell  in  advance  which  patients  harbor  organisms  in  the  vagina 
likely  to  prove  dangerous  later,  particularly  in  the  light  of  Williams' 
experiments,  effective  seemingly  to  prove  that  the  normal  vagina  during 
pregnancy  does  not  contain  pyogenic  organisms.  (4)  Focal  infection  in 
other  parts  of  the  body  may  be  the  underlying  cause  of  certain  cases 
of  peritonitis  which  develop  when  no  other  apparent  cause  can  be  found. 
It  has  been  definitely  proven  In  these  focal  infections  that  various  joints 
may  become  directly  infected  as  a  result  of  an  undrained  septic  process 
around  decayed  teeth  or  infected  tonsils.     It  is,  therefore,  perfectly 


COMPLICATIONS  OF  THE  CONVALESCENCE  135 

possible  that  organisms  may  reach  the  peritoneal  cavity  by  the  blood 
current,  and  the  peritoneal  resistance  being  lowered  as  a  result  of  the 
handling  at  operation,  find  a  favorable  soil  for  development. 

In  the  first  two  varieties  of  infection  the  symptoms  develop  shortly 
after  operation.  The  pulse  and  temperature  begin  to  rise  by  the  end 
of  twenty-four  hours.  Abdominal  distention  develops  early  and  in- 
creases steadily  in  spite  of  attempts  at  catharsis,  and  vomiting  is  apt  to 
be  an  early  and  persistent  symptom  in  spite  of  gastric  lavage.  Abdominal 
tenderness  is  present  from  an  early  period,  but  muscular  spasm  and 
rigidity  develop  late,  if  at  all.  The  patient  goes  down  hill  rapidly  and 
dies  in  a  few  days,  unless  the  wound  is  reopened  and  the  peritoneal  cavity 
drained  in  the  early  stages  of  the  infection,  and  even  then  the  prognosis 
is  grave  at  the  best,  while  if  the  infective  agent  is  a  virulent  one,  it  is 
practically  hopeless  from  the  first.  In  a  few  cases  incision  of  the  pos- 
terior vaginal  vault  with  through  and  through  drainage,  the  patient  be- 
ing placed  in  Fowler's  position,  may  limit  the  spread  of  the  infection 
and  result  in  recovery. 

In  cases  of  infection  due  to  slightly  virulent  organisms  the  symptoms 
are  slower  in  their  onset,  although  the  convalescence  is  abnormal  after 
the  first  day  or  two.  For  the  first  twenty-four  hours  or  so  the  pulse  and 
temperature  are  not  unduly  elevated  and  the  condition  may  be  mistaken 
for  the  ordinary  reaction  to  contamination  of  the  peritoneum  with  blood 
or  uninfected  liquor.  By  the  end  of  forty-eight  hours  after  operation  it 
is  fairly  evident  that  infection  is  taking  place  from  the  uterus,  and  there 
may  be  beginning  signs  of  peritoneal  involvement,  as  shown  by  beginning 
distention.  The  bowels  are  usually  to  be  moved  without  great  difficulty, 
and  gas  is  passed  freely,  though  the  distention  recurs  promptly  after  a 
short  period  of  relief.  Vomiting  is  not  a  prominent  symptom,  at  least 
in  the  early  stages.  If  the  abdomen  were  drained  at  this  stage  the  ma- 
jority of  patients  would  be  saved,  but  since  in  the  majority  of  cases  in 
this  condition  the  infection  remains  localized  to  the  uterus  and  pelvic 
peritoneum,  the  surgeon  naturally  hesitates  to  reopen  the  wound  for  a 
condition  the  nature  of  which  is  doubtful,  and,  therefore,  procrastinates 
until  the  extension  of  the  process  makes  it  evident  that  the  patient  is 
suffering  from  a  diffuse  and  spreading  peritonitis,  when  reoperation  is 
usually  too  late  and  merely  hastens  the  end. 

In  another  group  of  patients  of  this  class  the  symptoms  are  merely 
those  of  uterine  infection,  except  for  a  moderate  degree  of  intestinal 
distention,  which  may  be  no  more  marked  than  after  a  perfectly  clean 
laparotomy.  The  pulse  and  temperature  are  elevated,  there  is  no 
vomiting  and  the  bowels  are  moving  freely.     There  is  no  abdominal 


136  CESAREAN  SECTION 

spasm  and  tenderness  is  limited  to  the  region  of  the  uterus,  and  is  little, 
if  any,  more  marked  than  is  noted  in  uninfected  cases,  though  careful 
observation  will  show  that  it  is  increasing  from  day  to  day  instead  of 
growing  less,  as  it  should  do,  indicating  abscess  of  the  uterus. 

In  such  cases,  when  cesarean  section  has  been  performed  through  a 
low  incision,  the  uterus  will  often  become  adherent  to  the  wound  and 
eventually  the  abscess  may  drain  through  the  wound  in  some  instances, 
or  it  may  drain  through  the  uterine  cavity.  If  the  high  incision  has 
been  employed,  drainage  must  take  place  either  through  the  uterus  or 
into  the  peritoneal  cavity,  unless  the  abscess  is  drained  by  a  second 
operation.  If  rupture  takes  place  into  the  peritoneal  cavity,  the  symptoms 
become  acute.  The  patient  who  has  previously  been  showing  signs  of 
an  infection  but  who  has  not  seemed  unduly  sick,  is  seized  with  sudden 
abdominal  pain  which  may  be  extremely  severe,  and  promptly  goes  into 
collapse,  often  becoming  pulseless.  The  face  is  drawn  and  pinched  and 
the  general  condition  is  so  extremely  bad  that  it  is  evident  that  to  add 
to  the  shock  by  even  a  slight  operation  will  inevitably  prove  promptly 
fatal.  Relief  for  the  pain  should  be  given  by  morphia  and  active  stimula- 
tion should  be  employed  in  the  hope  that  the  patient  may  react  sufficiently 
to  allow  incision  and  drainage.  If  the  reaction  occurs,  drainage  may 
be  employed,  preferably  under  local  anesthesia,  but  the  outlook  is  not 
good.  If  the  patient  does  not  react,  there  is  little  use  in  attempting 
drainage,  since  any  interference  is  usually  promptly  fatal. 

In  cases  of  infection  secondary  to  the  extension  upwards  from  the 
vagina  the  symptoms  are  late  in  developing.  The  pulse  and  temperature 
are  elevated,  but  usually  only  slightly  so  at  first.  The  lochia  may  be 
suppressed  and  the  condition  mistaken  for  simple  interference  with  drain- 
age, due  to  lack  of  cervical  dilatation.  Dilating  the  cervix  gives  no 
relief,  however,  and  the  symptoms  increase  steadily,  and  unless  the 
wound  is  opened  and  the  peritoneal  cavity  drained  the  patient  often 
dies,  and  sometimes  even  then. 

Wound  Infection. — Wound  infection  and  stitch  abscess  are  occa- 
sional complications  of  any  abdominal  operation,  and  cesarean  section' 
is  not  immune,  in  fact  there  seems  to  be  a  somewhat  increased  liability. 
This  is  probably  due  to  the  fact  that  there  is  in  many  patients  an  in- 
creased fat  deposit  in  the  abdominal  wall  during  pregnancy,  and  fat  is 
prone  to  become  infected  and  break  down.  In  addition  many  of  these 
patients  are  operated  on  late  in  labor  and  the  abdominal  wound  is  ex- 
posed to  infection,  from  the  fact  that,  though  it  may  be  possible  to  pro- 
tect the  peritoneal  cavity  in  infected  cases,  it  is  not  possible  to  perfectly 
protect  the  abdominal  wall  and  more  or  less  infection  is  apt  to  occur. 


COMPLICATIONS  OF  THE  CONVALESCENCE  137 

If  the  infection  is  superficial,  it  is  of  no  particular  importance,  except 
that  it  delays  the  convalescence  and  is  to  be  treated  as  in  other  cases  of 
wound  infection,  i.e.,  provision  is  made  for  drainage  and  the  wound 
is  allowed  to  close  by  granulation  aided  by  tight  strapping  after  the  in- 
fection has  cleared  up.  Secondary  suture  to  accelerate  healing  may  be 
of  value  in  some  cases. 

If  the  infection  involves  the  whole  thickness  of  the  abdominal  wall, 
hernia  in  the  scar  is  apt  to  be  a  sequence,  since  the  wound  must  be 
opened  freely  and  packed.  Even  in  these  cases,  however,  hernia  may 
sometimes  be  prevented  by  tight  strapping  or  by  secondary  suture  after 
the  infection  has  cleared  up. 

Acute  Appendicitis. — Acute  inflammation  of  the  appendix  may 
complicate  the  convalescence  from  cesarean  section,  just  as  it  may  occur 
at  other  times  and  should  always  be  considered  as  a  possibility  in  any 
patient  who  develops  acute  abdominal  symptoms  during  an  otherwise 
normal  convalescence. 

I  have  seen  two  cases  in  my  experience.  In  one  an  abscess  about  a 
gangrenous  appendix  was  found  and  drained,  the  patient  recovering. 
The  other  patient  was  seen  in  consultation  already  moribund.  The  his- 
tory in  brief  was  that  after  three  days  of  a  normal  convalescence  the 
patient  developed  signs  of  an  acute  appendix  but  was  not  operated  on, 
and  after  two  days  the  appendix  ruptured  and  general  peritonitis  devel- 
oped, causing  the  death  of  the  patient. 

It  must,  therefore,  be  remembered  that  a  patient  is  not,  because  she 
has  had  a  recent  cesarean  section,  immune  to  any  other  disease,  but  that 
acute  symptoms  suggestive  of  trouble  outside  the  uterus  should  receive 
the  same  attention  that  they  would  call  for  under  normal  conditions, 
and  that  symptoms  suggestive  of  an  acute  attack  of  appendicitis  call 
for  operative  relief  just  as  at  other  times.  There  is  a  natural  hesitation 
to  reopen  the  abdomen  before  the  diagnosis  is  absolutely  certain,  espe- 
cially when  not  all  of  the  cardinal  symptoms  are  present.  Under  ordi- 
nary circumstances  spasm  and  rigidity  of  the  abdominal  wall  over  the 
inflamed  appendix  would  have  considerable  weight  in  deciding  the 
proper  treatment.  After  a  recent  delivery,  whether  or  not  by  the 
abdominal  route,  the  relaxed  condition  of  the  abdominal  walls  renders 
spasm  and  rigidity  of  little  value  as  guides  to  an  underlying  inflammatory 
condition,  and  if  marked  distention  is  present  and  the  abdomen  is 
tense,  little  or  nothing  can  be  learned  by  examination.  In  these  cases 
the  history  of  sharply  localized  pain  and  tenderness,  unless  the  abdomen 
is  markedly  distended,  taken  in  connection  with  the  pulse,  temperature 


138  CESAREAN  SECTION 

and  leukocytosis,  may  call  for  an  operation  when  the  physical  findings 
would  hardly  justify  it. 

LITEEATUEE 

AsPELL,  J.  Four  Caesarean  Operations  complicated  by  Fibromata  in 
which  Hysterectomy  was  Performed.  N.  Y.  Med,  Jr.  Sept.  i, 
1906. 

Breitstein,  L.  I.  Rupture  of  the  Uterus  Following  Caesarean  Sec- 
tion.    Jr.  Am.  Med.  A.     Feb.  28,  19 14. 

Brodhead,  G.  L.  Rupture  of  the  Uterus  through  the  Caesarean  Cica- 
trix.   Am.  Jr.  Obst.     1908.    V.  57. 

Dahlmann,  a.  Zerreisungen  der  Gebarmutter  nach  Kaiserschnitt. 
Monschr.  f.  Gebh.  u.  Gyn.     v.  31. 

Descusses,  G.  I2tude  sur  I'operation  cesarienne  et  I'accouchement 
methodiquement  rapide.    These  de  Paris  No.  162.     1908. 


CHAPTER  XI 

STERILIZATION   OF  THE  PATIENT  AT  THE  TIME  OF  OPERATION 

Sterilization  Sometimes  Justifiable — To  Avoid  Repeated  Operations — Not  Advisable 
at  First  Operation  Unless  Organic  Disease  Contra-indicates  Future  Pregnancies — 
In  Cardiac  Disease — In  Chronic  Nephritis — Methods  of  Sterilization. 

No  discussion  of  cesarean  section  can  be  complete  without  considera- 
tion of  the  advisabihty  of  steriHzing  patients  before  the  abdomen  is 
closed  when  cesarean  section  has  been  performed,  and  the  operator 
feels  that  if  the  patent  becomes  pregnant  at  some  future  time,  cesarean 
section  must  be  the  means  of  delivery.  A  considerable  literature  has  ac- 
cumulated on  the  subject,  some  writers  taking  the  ground  that  sterili- 
zation is  never  permissible  under  any  circumstances,  while  others  advo- 
cate it  as  a  routine  procedure  at  the  time  of  the  second,  if  not  of  the  first, 
operation  and  still  others  believe  that  the  question  should  be  left  to  the 
patient  and  her  husband  for  decision. 

That  sterilization  is  not  a  necessary  procedure  on  account  of  the 
necessity  of  repeated  sections  is  shown  by  the  fact  that  series  of  opera- 
tions are  reported  in  which  cases  have  been  delivered  three,  four,  and 
five  times  by  section,  and  I  have  seen  one  patient  who  has  had  six  sections 
successfully.  Furthermore,  the  risk  of  each  successive  operation  is  no 
greater  than  the  risk  of  the  primary  operation,  and  in  cases  in  which  no 
organic  disease  contra-indicates  future  pregnancies  the  rights  of  the 
patient  should  be  considered  and  the  question  should  be  left  to  her  and 
her  husband  for  decision,  if  they  are  of  normal  intelligence,  since  the 
patient  has  a  right  to  decide  whether  she  will  undergo  repeated  preg- 
nancies, each  of  which  must  end  in  cesarean  section,  or  at  best  live  in 
constant  fear  of  the  same,  or  be  protected  against  the  risks  of  preg- 
nancy and  repeated  laparotomy.  Abortion  is  not,  in  my  opinion,  to  be 
considered  as  an  alternative  in  these  cases,  unless  the  risks  of  repeated 
cesarean  section  are  thought  to  be  too  great,  and  even  then  repeated 
abortion  should  never  be  considered,  and  the  patient  should  be  steri- 
lized to  avoid  its  necessity. 

In  general  it  may  be  said  that  a  patient  should  not  as  a  rule  be  steri- 
lized at  the  time  of  the  first  cesarean  section,  unless  some  organic  lesion 

139 


140  CESAREAN  SECTION 

exists  which  renders  the  recurrence  of  pregnancy  dangerous  or  un- 
desirable. In  healthy  women  the  dangers  of  a  second  operation  are 
so  slight  that  I  do  not  feel  the  attendant  is  justified  in  suggesting  steri- 
lization at  the  time  of  the  first  section,  and  even  if  the  patient  requests 
it,  he  should  urge  on  her  very  strongly  the  disadvantages  of  a  one  child 
marriage  and  the  fact  that,  if  she  is  sterilized  and  the  child  should  die 
later,  it  may  prove  a  matter  of  lifelong  regret  to  her  that  she  can  have  no 
other  children.  He  should  be  willing,  however,  if  she  asks  for  informa- 
tion, to  give  her  definite  instructions  as  to  the  best  means  of  avoiding 
pregnancy,  always  informing  her  that  no  method  of  prevention  is  sure 
except  abstinence  from  exposure. 

If,  however,  any  condition  is  present  which  renders  future  pregnancies 
dangerous  to  the  life  or  health  of  the  mother,  e.g.,  heart  lesions,  chronic 
nephritis,  etc.,  or  if  the  cesarean  section  has  been  rendered  necessary 
by  the  results  of  operation  to  repair  the  damage  suffered  at  previous 
labors,  and  the  patient  has  other  living  children,  the  attending  surgeon 
is  justified  in  urging  the  propriety  of  sterilization,  or  at  least  in  sug- 
gesting the  possibility  of  its  performance,  so  that  the  patient  and  her 
husband,  being  in  full  possession  of  the  facts,  may  consider  the  question 
carefully.  In  other  words,  if  any  condition  is  present  which  may  pos- 
sibly render  future  pregnancies  dangerous  to  the  life  of  the  mother,  or 
leave  her  in  such  a  condition  that  she  may  be  more  or  less  seriously 
invalided,  the  advisability  of  completing  the  operation  by  some  pro- 
cedure which,  without  adding  to  the  immediate  risks  appreciably,  will 
remove  this  source  of  danger  for  the  future,  is  properly  to  be  suggested. 

In  patients  with  cardiac  disease  who  have  had  attacks  of  decom- 
pensation, either  in  the  non-pregnant  state  or  during  pregnancy,  steri- 
lization at  the  time  of  operation  should  be  most  strongly  urged  as  a  life 
or  health  saving  procedure.  In  these  patients  the  strain  of  repeated 
pregnancies  on  the  damaged  heart  is  sure  to  be  detrimental,  and  may 
prove  fatal,  and  unless  operation  is  refused,  I  do  not  feel  that  the 
surgeon  has  done  his  duty  by  his  patient  unless  he  leaves  her  in  such  a 
condition  that  the  danger  of  repeated  pregnancies  is  removed  for  good. 

If  a  patient  who  has  had  one  cesarean  section  comes  to  operation  a 
second  time,  the  attendant  may  be  justified  in  suggesting  the  propriety  of 
sterilization,  even  though  she  may  be  in  perfect  health.  The  operation 
should  not  be  urged  in  these  cases,  but  the  facts  should  be  placed  squarely 
before  the  patient,  and  it  should  be  left  to  her  to  decide  whether,  having 
two  healthy  children,  she  wishes  to  be  left  in  a  condition  in  which  preg- 
nancy may  occur  again,  with  or  without  her  volition,  and  find  it  neces- 
sary to  undergo  the  dangers  and  discomforts  of  future  pregnancies  with 


STERILIZATION  OF  PATIENT  AT  TIME  OF  OPERATION       141 

the  surety  of  an  abdominal  delivery  at  the  end,  or  whether  she  prefers 
to  know  that  pregnancy  will  be  impossible  in  the  future.  In  my  experi- 
ence the  majority  of  women  fear  cesarean  section  so  httle  that  they 
prefer  to  undergo  repeated  operations  in  the  absence  of  conditions  which 
render  pregnancy  unduly  dangerous,  rather  than  to  feel  that  they  will 
be  deprived  of  the  right  of  choice  as  to  whether  they  will  have  other 
children,  if  at  a  later  date  it  may  seem  desirable;  and  furthermore  to 
many  women  the  fact  that  they  have  been  rendered  sterile  is  more 
repugnant  than  the  possibility  of  future  sections,  in  spite  of  the  risks 
which  may  arise,  if  pregnancy  ensues. 

There  remains  another  class  of  patients,  however,  for  whom  the  ad- 
visability of  abdominal  abortion  and  sterilization  cannot  be  too  strongly 
recommended.  This  group  includes  the  patients  who  have  serious  or- 
ganic disease,  to  whom  pregnancy  is  a  serious  menace,  and  who  face  the 
alternative  of  death  or  serious  illness  if  pregnancy  occurs  and  is  not  in- 
terrupted. First  in  this  class  stand  patients  who  have  serious  organic 
heart  lesions,  particularly  mitral  stenosis.  Given  a  patient  with  a  serious 
cardiac  lesion  who  has  had  even  a  single  severe  attack  of  decompensa- 
tion during  previous  pregnancies,  or  when  not  pregnant,  and  who,  be- 
coming pregnant  again,  suffers  from  decompensation  early  in  this  preg- 
nancy, abortion  and  sterilization  offer  the  only  chance  certainly  for 
future  health  and  possibly  for  life.  If  compensation  can  be  restored  by 
rest  and  the  use  of  digitalis,  the  operation  can  be  performed  at  one  sit- 
ting, the  ovum  being  removed  from  the  uterus  by  hysterotomy  and  the 
patient  sterilized  at  the  same  time.  If  compensation  cannot  be  restored 
while  the  pregnancy  persists  and  the  patient  is  in  such  condition  that 
laparotomy  seems  inadvisable  at  the  moment,  the  uterus  should  be 
emptied  by  the  most  conservative  method  and  the  sterilization  deferred 
until  the  improvement  in  the  patient's  condition  warrants  it. 

The  same  holds  true  in  patients  with  advanced  chronic  nephritis 
who  have  had  repeated  miscarriages  or  still  births.  In  these  cases  it 
must  be  remembered  that  each  attempt  at  pregnancy  increases  the  renal 
damage  and  shortens  the  patient's  life.  Since  past  experience  has  proved 
that  the  chances  of  a  living  child  are  practically  nothing,  the  mother's 
interests  are  the  only  ones  to  be  considered,  and  the  pregnancy  may 
very  properly  be  ended  for  the  sake  of  reducing  the  damage  which  the 
continuance  of  pregnancy  will  inflict  on  her  kidneys.  Since  a  simple 
abortion  leaves  her  in  a  condition  to  become  pregnant  again,  it  is  an 
incomplete  operation,  and  delivery  by  the  abdominal  route  followed  by 
sterilization  is  the  indicated  procedure. 

Similar  treatment  may  Ije  called  for  in  patients  who  have  suffered 


142  CESAREAN  SECTION 

from  dementia  at  some  previous  time  in  their  lives  and  who  develop 
symptoms  of  a  new  attack  during  pregnancy.  Such  women  should  not 
be  subjected  to  repeated  pregnancies,  even  though  the  present  one  is  not 
interfered  with,  and  cesarean  section  followed  by  sterilization  may  prop- 
erly be  considered  as  the  best  method  of  delivery. 

Methods  of  Sterilization. — Various  methods  of  sterilization  are 
possible  and  in  general  it  may  be  said  that  each  has  advantages  and  dis- 
advantages of  its  own  under  certain  conditions. 

Removal  of  the  ovaries  is  the  most  obvious  method,  but  is  distinctly 
the  least  desirable  of  the  methods  to  be  considered,  except  in  women  with 
osteomalacia,  in  whom  it  may  prove  the  cure  of  the  disease.  It  is  only 
justifiable  otherwise  in  women  at  or  near  the  menopause,  in  whom  the 
ovaries  are  extensively  diseased  or  when  for  some  reason  it  is  thought 
necessary  to  remove  all  the  pelvic  organs,  as  in  early  carcinoma,  when 
the  ovaries  are  removed,  not  for  sterilization,  but  as  part  of  an  exten- 
sive operation  in  the  attempt  to  eradicate  the  disease. 

Inversion  of  the  fimbriated  extremities  of  the  tubes  and  closure  of 
the  outer  ends  by  suture  has  been  recommended  and  in  most  cases  is  un- 
doubtedly efficient.  In  some  cases,  however,  it  is  conceivable  that  the 
closure  may  not  be  perfect  or  that  the  adhesions  formed  may  be  absorbed, 
cases  having  been  reported  in  which  pregnancy  has  followed  such  an 
operation,  and  since  more  certain  means  are  available,  this  method  is 
not  to  be  advised.  Burying  the  fimbriated  extremities  of  the  tubes  in 
the  broad  ligaments  has  been  suggested  recently.  In  this  operation  a 
short  incision  is  made  in  the  peritoneal  coat  of  the  anterior  surface  of 
each  broad  ligament  and  the  fimbriated  end  of  the  tube  inserted,  the 
peritoneum  being  sutured  over  all.  It  is  a  simple  procedure  and  prob- 
ably effective.  This  method  has  been  particularly  suggested  for  confer- 
ring temporary  sterility  on  patients  with  a  temporary  contra-indication 
to  pregnancy  and  it  has  been  suggested  that,  if  pregnancy  seems  de- 
sirable at  some  future  time,  the  operation  may  be  undone  with  a  fair  hope 
of  success. 

Double  ligation  of  the  tubes  with  division  between  the  ligatures  has 
been  a  common  procedure,  but  in  some  cases  the  canal  of  one  or  both 
tubes  has  been  reestablished  after  absorption  of  the  ligatures  and  preg- 
nancy has  followed,  showing  that  this  method,  though  usually  successful, 
is  not  to  be  depended  on. 

Supravaginal  amputation  of  the  body  of  the  uterus  is  an  absolutely 
certain  method  of  preventing  future  pregnancies  and  is  to  be  advised  in 
certain  classes  of  cases,  especially  when  the  body  of  the  uterus  is  the 
seat  of  fibroid  tumors,  or  when  any  suspicion  of  infection  before  opera- 


STERILIZATION  OF  PATIENT  AT  TIME  OF  OPERATION       143 

tion  is  entertained.  It  has  the  disadvantage  of  adding  somewhat  to  the 
risk  of  the  operation,  and,  therefore,  is  preferably  not  performed  unless 
some  further  indication  is  present  than  merely  the  desire  to  prevent  future 
pregnancies. 

The  most  satisfactory  method  of  sterilization,  in  the  great  majority 
of  cases,  is  the  excision  of  the  proximal  ends  of  the  tubes  from  the  cor- 
nua  of  the  uterus  by  V  shaped  incisions.  The  wounds  in  the  uterus  are 
then  sutured  and  covered  with  peritoneum  and  the  ends  of  the  tubes 
are  buried  in  the  folds  of  the  broad  ligament  and  covered  with  peri- 
toneum. This  is  a  simple  procedure,  which  adds  only  a  few  minutes  to 
the  length  of  the  operation  and  nothing  to  its  risks;  it  does  not  inter- 
fere with  future  menstruation  and  is  absolutely  certain  in  its  results. 
It  has  the  further  advantage  that,  if  the  patient  desires  at  some  future 
time  to  have  children,  a  second  operation  to  implant  the  tubes  in  the 
uterine  cornua  may  be  performed,  and  offers  a  slight  chance  of  success, 
although  nothing  can  be  promised  from  it. 

Of  course,  it  may  be  urged  that  such  operations  are  unnecessary  and 
improper,  and  that  the  true  remedy  against  pregnancy  lies  in  conti- 
nence on  the  part  of  the  patient  and  her  husband.  This  is  a  perfectly 
proper  criticism  in  the  cases  in  which  sterilization  is  performed,  because 
the  patient  fears  future  cesarean  sections  and  wishes  to  avoid  them. 
However,  in  patients  to  whom  pregnancy  is  a  serious  menace  and  whose 
lives  may  be  sacrificed  if  conception  occurs,  unless  an  abortion  is  promptly 
done,  sterilization  is,  in  my  opinion,  not  only  justifiable  but  almost  obliga- 
tory, since  accidents  happen  in  spite  of  all  precautions,  and  in  these 
patients  nothing  should  be  left  to  chance  and  the  patient  must  be  pro- 
tected against  herself.  It  is  very  easy  to  adopt  a  high  moral  tone  and 
argue  that  abstinence  from  intercourse  is  the  simple  and  easy  method 
of  solving  the  problem,  but  experience  has  proved  otherwise,  and  I  have 
seen  too  many  lives  sacrificed  because  the  physician  contented  himself 
with  advise  as  to  what  must  not  occur,  without  taking  steps  to  see  that 
his  advice  was  taken,  not  to  feel  that,  if  I  am  willing  to  say  to  a  patient 
and  her  husband  that  pregnancy  must  under  no  circumstances  occur 
again,  I  have  failed  in  my  duty  to  such  a  patient  unless  I  am  also  willing 
to  permanently  remove  the  danger.  This  is  particularly  the  case  when 
the  abdomen  is  already  opened  and  the  added  procedure  entails  no  added 
risk  to  the  patient. 


CHAPTER    XII 

SPECIAL  METHODS  OF  OPERATION 

Porro  Operation — Supravaginal  Hysterectomy — Indications — Technic  of  the  Porro 
Operation — Technic  of  Supravaginal  Hysterectomy — Panhysterectomy — Bibli- 
ography. 

It  has  been  generally  recognized,  ever  since  Porro  published  his 
monograph  in  1876,  that  under  certain  conditions  removal  of  the  uterus 
in  part  or  as  a  whole  after  the  performance  of  cesarean  section  adds 
greatly  to  the  safety  of  the  patient.  When  Porro  first  described  his 
operation  the  maternal  mortality  of  cesarean  section  was  so  appalling, 
that  abdominal  delivery  was  considered  only  when  all  other  methods 
had  been  tried  and  had  failed,  leaving  cesarean  section  as  the  only  chance 
for  the  patient,  the  only  alternative  being  to  allow  her  to  die  unde- 
livered. The  introduction  of  the  Porro  operation  led  to  such  an  improve- 
ment in  the  results  of  abdominal  delivery  that  for  a  time  it  enjoyed 
marked  popularity,  and  although  the  technic  has  been  modified  to  keep 
pace  with  the  improvements  in  surgery,  the  operation  for  amputation  of 
the  uterus  at  about  the  level  of  the  internal  os  is  still  commonly  spoken 
of  as  the  Porro  cesarean  section. 

Experience  with  the  conservative  cesarean  section  has  proved  that 
the  high  mortality  of  early  days  was  due  to  two  factors;  first,  that  the 
operation  was  seldom  or  never  performed  on  favorable  cases,  but  was 
an  operation  of  last  resort,  only  to  be  considered  for  patients  in  whoni 
attempts  at  delivery  by  other  means  had  proved  futile;  and  second,  be- 
cause the  uterus  was  not  sutured,  but  was  dropped  back  into  the  abdo- 
men at  the  end  of  operation,  to  act  as  a  source  of  hemorrhage  and  ih- 
fection.  Furthermore,  asepsis  was  unknown.  Taking  these  facts  into 
consideration,  the  wonder  is  not  that  the  mortality  was  so  great,  but 
that  any  patients  survived. 

The  Porro  operation  was  devised  to  eliminate  the  danger  of  return- 
ing the  probably  infected,  bleeding  uterus  to  the  abdomen,  and  fulfilled 
its  purpose  excellently. 

When  Sanger  published  his  great  work  in  1882,  which  forms  the 
basis  of  the  modern  cesarean  section,  it  was  enthusiastically  received 
and  the   Porro  operation  was  largely  given  up.     Further  experience 

144 


SPECIAL  METHODS  OF  OPERATION  145 

proved,  however,  that  in  patients  who  were  already  infected  at  the  time 
of  operation  the  results  of  the  conservative  operation  were  unsatisfac- 
tory, and  the  modified  Porro  operation  was  revived  for  use  in  those 
cases.  At  the  present  time  the  operation  of  supravaginal  hysterectomy 
has  superseded  the  earlier  Porro  operation,  but  the  indications  for  its 
performance  are  the  same. 

Indications  for  Removal  of  the  Uterus. — The  performance  of  an 
abdominal  delivery  on  patients  already  known  or  supposed  to  be  in- 
fected is  contra-indicated  whenever  any  other  means  of  delivery,  even 
of  a  mutilated  child,  is  possible,  unless  the  child  is  in  good  condition  and 
the  parents  elect  that  its  life,  for  religious  or  other  reasons,  compensates 
for  a  very  serious  risk  to  the  mother,  after  having  had  the  facts  care- 
fully explained  to  them.  If  the  life  of  the  child  is  chosen  at  the  possible 
expense  of  the  mother,  or  if  the  pelvic  contraction  is  so  marked  that 
delivery  from  below  is  impossible,  or  carries  with  it  dangers  believed 
to  be  practically  as  great  as  those  attendant  on  cesarean  section  under  the 
circumstances,  the  operation  may  be  properly  undertaken,  a  very  grave 
prognosis  being  given.  In  these  cases,  however,  it  should  either  be 
performed  extraperitoneally  or,  preferably,  the  uterus,  instead  of  being 
sutured  and  returned  to  the  abdominal  cavity,  should  be  amputated  and 
removed,  since  it  adds  greatly  to  the  danger,  if  the  infected  uterus  is 
replaced  in  the  abdominal  cavity,  to  act  as  a  source  of  peritoneal  infec- 
tion. 

In  other  cases,  as  for  instance  when  the  pregnant  uterus  is  the  seat 
of  multiple  myomata  which  require  operation  in  any  case,  the  conservative 
treatment  is  cesarean  section  followed  by  supravaginal  amputation,  to 
save  the  patient  from  the  dangers  of  a  second  abdominal  operation  at 
a  later  date  for  the  removal  of  the  tumors. 

In  cases  of  premature  separation  of  the  placenta,  for  which  cesarean 
section  has  been  performed,  it  will  occasionally  be  found  that,  on  account 
of  the  disintegration  of  the  uterine  musculature  by  the  hemorrhage 
which  has  taken  place  into  it,  the  contractile  power  of  the  uterus  has  been 
destroyed  and  the  uterus  cannot  be  stimulated  to  contraction.  To  return 
such  a  uterus  to  the  abdominal  cavity,  even  after  suture,  is  merely  to 
invite  disaster  from  postpartum  hemorrhage,  and  the  only  safe  treat- 
ment is  removal  of  the  uterus. 

Atony  of  the  uterus  with  increased  hemorrhage  is  also  seen  in  cer- 
tain other  conditions,  notably  overdistention  of  the  uterine  musculature, 
whether  as  a  whole  or  in  part.  The  action  of  the  uterus  should  be  care- 
fully watched,  therefore,  after  the  delivery  of  multiple  pregnancies  or  in 
cases  of  hydramnios,   and  particularly  in  cases  of  sacculation   of  the 


146  CESAREAN  SECTION 

uterus,  in  which  the  section  was  necessitated  by  dystocia  following  fixa- 
tion of  the  uterus  to  the  abdominal  wall  in  faulty  suspension  operations. 
In  the  latter  class  of  cases  the  development  of  the  anterior  uterine  wall 
during  pregnancy  is  seriously  interfered  with,  if  not  practically  prevented, 
by  the  firm  adhesions  between  it  and  the  abdominal  wall,  and  the  posterior 
wall,  which  has  been  markedly  overdistended,  is  very  thin  and  has  in  some 
cases  practically  lost  its  power  of  contraction.  This  condition  predis- 
poses markedly  to  postpartum  hemorrhage  and  the  uterus  should  be 
stimulated  to  contraction  by  all  possible  expedients.  If,  however,  it  does 
not  contract  satisfactorily  within  a  reasonable  time,  and  especially  if  any 
appreciable  amount  of  hemorrhage  occurs,  a  supravaginal  amputation 
should  be  promptly  performed,  since  it  is  an  absolutely  unsurgical  pro- 
cedure to  replace  a  relaxed  and  bleeding  uterus  when  it  has  proved  im- 
possible to  provoke  adequate  contraction,  whether  mechanically  or  by  the 
use  of  drugs. 

Porro  Cesarean  Section. — The  operation  as  described  by  Porro — 
for  removal  of  the  uterus — is  seldom  performed  at  the  present  time,  but 
no  discussion  of  cesarean  section  would  be  complete  unless  it  contained 
a  brief  description  of  its  technic. 

Until  the  child  is  delivered  the  steps  of  the  operation  are  identical 
with  those  of  the  conservative  cesarean  section.  In  the  Porro  operation, 
however,  it  is  not  necessary  to  remove  the  placenta  from  the  uterine 
cavity,  since  the  body  of  the  uterus  is  to  be  amputated,  although  this 
may  be  done  if  the  operator  prefers.  As  soon  as  the  child  is  delivered 
an  elastic  ligature  is  tied  tightly  around  the  upper  portion  of  the  cervix. 
The  infundibulopelvic  ligaments  are  now  ligated  and  cut  through  and 
the  uterus  is  then  amputated  a  short  distance  above  the  elastic  ligature. 
A  long  knitting  needle  is  now  passed  through  the  stump  and  allowed 
to  rest  on  the  abdominal  walls,  preventing  the  cervix  from  slipping  back 
into  the  abdominal  cavity,  the  remainder  of  the  wound  being  closed  by 
sutures  in  the  ordinary  manner.  In  a  short  time  the  stump  and  elastic 
ligatures  slough  off,  leaving  a  depressed  wound,  which  heals  by  granu- 
lation. 

The  operation  is  a  simple  procedure  and  quickly  done,  but  owing  to 
the  long  and  complicated  healing  process  necessary  and  the  unsightly 
appearance  of  the  resulting  scar,  which  is  deeply  retracted  beneath  the 
proper  level  of  the  abdominal  walls,  it  is  rarely  employed  at  the  presjent 
time. 

Supravaginal  Hysterectomy. — The  Porro  operation  has  been 
practically  superseded  in  modern  times  by  supravaginal  amputation  of  the 
body  of  the  uterus,  the  tubes  and  ovaries  being  left.  Practically  the  same 


SPECIAL  METHODS  OF  OPERATION  147 

technic  is  employed  as  in  the  non-pregnant  condition,  and  if  the  Tren- 
delenburg position  is  used  the  operation  will  be  much  facilitated. 

The   child   is   delivered  as   in  the  ordinary   conservative  operation, 
except  that,  in  the  cases  of  supposed  infection  of  the  uterus,  a  sufficiently 


Fig.  33. — Cesarean  Section  with  Supravaginal  Hysterectomy:  Tubes  and 
Ovaries  Retained:  Placenta  Undelivered. 

I,  Round  ligament  clamped ;  2,  tube  and  broad  ligament  clamped;  3,  anterior 
peritoneal  flap;  4,  uterine  artery  clamped;  5,  incision  in  cervix. 

long  abdominal  incision  is  made  to  permit  the  delivery  of  the  unopened 
uterus  from  the  abdomen  and  the  complete  protection  of  the  peritoneal 
cavity  by  gauze  packing,  so  that  the  danger  of  infection  of  the  peritoneum 
by  the  infected  uterine  contents  is  reduced  to  a  minimum.    The  placenta 


148 


CESAREAN  SECTION 


is  ordinarily  left  in  utero.  The  patient  is  now  placed  in  the  Trendelen- 
burg position.  The  tubes,  ovarian,  and  round  ligaments  on  each  side  are 
ligated  a  short  distance  from  the  uterus,  clamps  are  placed  between  the 
uterus  and  the  ligatures,  and  the  tissues  between  the  clamps  and  liga- 
tures are  divided.     The  broad  Hgament  on  either  side  is  divided  down 


Fig.  34. — Cesarean   Section  with   Supravaginal   Hysterectomy. 
Method  of  suturing  cervical  stump :  tubes  and  ovaries  intact. 

to  its  base.  A  curved  incision  is  now  made  across  the  anterior  surface 
of  the  uterus  just  above  the  bladder  reflection  and  a  peritoneal  flap 
peeled  off  by  blunt  dissection.  The  uterine  arteries  are  then  isolated,  tied, 
and  cut,  and  the  body  of  the  uterus  is  amputated  at  the  cervical  junc- 
tion. The  cervical  canal  is  cauterized,  either  by  the  actual  cautery  or  by 
crude  carbolic  acid,  and  the  stump  is  sutured  so  as  to  close  and  bury 


SPECIAL  METHODS  OF  OPERATION  149 

the  canal  by  the  necessary  numl^er  of  catgut  sutures,  covered  by  the 
peritoneal  flap,  and  then  dropped  back  into  the  peritoneal  cavity.  The 
broad  ligament  wounds  are  closed  with  continuous  catgut  sutures.  The 
gauze  packing  is  then  removed  and  the  pelvic  cavity  is  sponged  out  care- 
fully and  the  abdominal  wound  closed.  In  infected  cases  it  is  a  wise  pre- 
caution to  sponge  out  the  pelvis  with  70  per  cent  alcohol  and  a  small 
amount  may  be  left  in  the  abdomen. 

The  operation  is  a  simple  one  for  the  operator  who  has  had  a  proper 
surgical  training  and  can  be  completed  more  cjuickly  than  a  conservative 
cesarean  section.  The  relaxed  condition  of  the  pelvic  floor  and  the 
abdominal  walls  makes  it  possible  to  bring  the  upper  part  of  the  cervix 
out  through  the  incision,  so  that  the  entire  operation  can  be  completed 
on  the  surface  of  the  abdomen,  instead  of  deep  in  the  pelvis,  as  in  the 
non-pregnant  condition.  In  spite  of  the  improved  results  which  follow 
the  extraperitoneal  methods  of  cesarean  section  in  doubtful  cases,  the 
danger  to  the  patient  of  leaving  the  uterus  in  cases  of  frank  infection  is 
so  great  that  I  believe  this  to  be  the  operation  of  election  for  infected 
cases. 

Total  Hysterectomy. — Removal  of  the  entire  uterus  after  cesarean 
section  was  first  done  by  Bischoff.  The  operation  is  somewhat  more 
difficult  than  supravaginal  amputation  and  carries  with  it  a  distinctly 
higher  mortality.  It  is,  therefore,  seldom  done  except  in  cases  of  early 
carcinoma  of  the  cervix,  which  are  considered  operable,  or  in  rare  cases 
of  infection  when  it  is  felt  that  retention  of  the  infected  cervix  will 
militate  against  the  patient's  chances  of  recovery.  As  a  rule,  if  per- 
formed under  thoroughly  aseptic  technic,  the  results  are  satisfac- 
tory. Owing  to  the  fact  that  the  vaginal  vault  is  opened,  a  careful 
vaginal  preparation  must  be  performed  before  the  operation  is  under- 
taken. 

The  technic  is  identical  with  that  of  supravaginal  amputation  of  the 
uterus,  except  that  after  ligation  of  the  uterine  arteries  the  vaginal  vault 
is  incised  and  the  entire  uterus  removed.  The  opening  into  the  vagina  is 
now  closed  with  catgut,  the  broad  ligament  wounds  are  sutured  with  a 
continuous  catgut  suture,  and  the  abdomen  is  closed. 

Some  operators  prefer  total  hysterectomy  in  all  cases,  urging  the 
possibility  of  future  cancer  of  the  cerv-ix  if  the  cervix  is  left  behind. 
Cases  of  cancer  of  the  cervical  stump  are  reported  from  time  to  time, 
but  I  feel  that  this  danger  is  less  than  the  increased  immediate  mortality 
of  the  more  radical  operation. 


ISO  CESAREAN  SECTION 

LITEEATURE 

BiscHOFF.  Die  Totale  Exstirpation  des  Schwangeren  und  Carcino- 
matosen  Uterus.     Cor.-Bl.  f.  Schw.  Artze.     1880.     No.  6. 

CoE,  H.  C.  Caesarean  Section :  Suture  of  the  Uterus  versus  Total 
Extirpation.     Med.  News.     May  30,  1896. 

Davis,  A.  B.  Modern  Methods  in  Cesarean  Section.  Am.  Jr.  Obst. 
1912.     V.  66. 

McPherson,  R.  Abdominal  Caesarean  Section.  Jr.  Am.  Med.  A. 
1908.    51:734- 

Indications  for  Abdominal  Cesarean  Section  with  the  Technic 

of  the  Operation.     Am.  Jr.  Obst.     1912,     v.  66. 

PoRRO.     Delia  amputazione  utero-ovarica.      Milan,    1876. 

RiCKETTS,  B.  M.  Suprapubic  Cesarean  Section  for  Puerperal  Eclamp- 
sia.    Am.  Jr.  Surg.     1914. 

Sanger.     Der   Kaiserschnitt  bei  Uterusmyomen.      Leipzig,    1882. 

Thomas,  T.  G.  Gastro-elytrotomy :  A  Substitute  for  the  Caesarean 
Section.    Am.  Jr.  Obst.     1871.    3:125. 


CHAPTER  XIII 

EXTRA-  AND  TRANSPERITONEAL   CESAREAN   SECTIONS 

History  of  Extraperitoneal  Cesarean  Section — Unnecessary  in  Clean  Cases — Not  Ef- 
ficient in  Frankly  Infected  Cases — Indications  for  Extraperitoneal  Operations — 
Methods  of  Operation — Extraperitoneal  Operation — Kiistner's  Modification — 
Latzko's  Operation — Transperitoneal  Operation — Hirst's  Modification — Bibli- 
ography. 

In  the  preceding  chapters  the  discussion  has  practically  been  limited 
to  the  classical  cesarean  section  with  its  indications  and  limitations,  both 
of  which  it  is  possible  to  define  with  a  reasonable  degree  of  accuracy,  and 
it  would  seem  as  if  little  more  could  be  added  which  would  prove  of 
value.  During  the  last  few  years,  however,  many  operators,  beginning 
with  Frank  in  1907,  have  been  experimenting  with  various  modifications 
of  the  operation,  in  the  hope  of  widening  the  field  of  its  indications  by 
the  discovery  of  some  method  by  M^'hich  the  obvious  disadvantages  might 
be  eliminated  when  it  is  performed  on  patients  who  do  not  come  within 
the  favorable  class.  These  procedures  aim  at  protection  of  the  peritoneal 
cavity,  so  that  a  living  child  may  be  delivered  by  the  abdominal  route 
from  uteri  already  infected,  or  thought  to  be  probably  infected,  without 
subjecting  the  mother  to  the  dangers  which  are  recognized  as  unavoidable 
when  the  classical  operation  has  been  performed  on  unfit  or  doubtful 
cases.  The  various  procedures  have  been  designated  extra-  or  trans- 
peritoneal sections,  according  to  the  method  employed  in  reaching  the 
uterus  before  it  is  incised.  In  the  former  the  attempt  is  made  to  reach 
the  lower  segment  of  the  uterus  by  separation  of  the  peritoneum  from 
its  pelvic  attachments,  without  opening  the  general  peritoneal  cavity,  and 
to  remove  the  child  from  the  lower  uterine  segment  after  dissecting  the 
bladder  from  its  attachments  to  the  anterior  wall  of  the  uterus ;  while  in 
the  latter  the  peritoneal  cavity  is  opened  in  order  to  reach  the  lower 
uterine  segment,  but  is  closed  by  suture,  clamps,  or  packing  before  the 
uterus  is  incised,  in  the  hope  that  the  child  can  be  removed  from  the 
infected  uterus  and  the  uterine  wound  closed  and  buried  under  the 
bladder  without  contamination  of  the  peritoneal  cavity,  thus  diminishing 
to  a  large  extent  the  danger  of  peritoneal  infection.  The  results  of  these 
attempts  have  proved  interesting  and  to  a  certain  extent  significant,  but 
a  more  extensive  period  of  experimentation  is  necessary  before  the  classi- 

151 


152  CESAREAN  SECTION 

cal  operation  can  be  considered  as  superseded  in  clean  cases,  although  this 
may  eventually  prove  to  be  the  case. 

The  development  of  the  extra-  and  transperitoneal  operations  is  the 
result  of  the  fact  that  the  medical  profession  as  a  whole  does  not  as  yet 
appreciate  that  proper  prenatal  study  of  the  patient  in  the  last  few  weeks 
of  pregnancy,  or  failing  this,  careful  observation  of  labor  during  the  first 
few  hours,  will  determine  in  the  great  majority  of  cases  what  method 
of  delivery  will  best  serve  the  interests  of  the  given  patient,  so  that  the 
indicated  operation  can  be  performed  while  the  patient  is  still  in  a  proper 
condition  to  render  a  favorable  outcome  almost  certain. 

Experience  has  proved  that  the  classical  cesarean  section  is  a  'rela- 
tively safe  operation  when  the  rules,  which  have  been  formulated  in  the 
previous  chapters,  are  followed,  and  the  majority  of  bad  results  are  due 
to  a  lack  of  appreciation  of  the  rules,  or  to  a  deliberate  disregard  of  them. 
A  certain  mortality,  however,  attends  the  operation,  even  when  it  is  per- 
formed on  patients  believed  to  be  absolutely  favorable,  and  although  at 
first  the  extraperitoneal  operations  were  undertaken  in  the  hope  that 
patients  who  were  more  or  less  unfit  for  abdominal  delivery  might  be 
safely  operated  on  by  these  methods,  various  operators  have  discarded 
the  classical  operation  within  the  last  few  years  in  favor  of  some  extra- 
peritoneal modification,  in  the  hope  of  eliminating  the  few  bad  results 
which  occur  in  relatively  favorable  cases. 

The  reports  of  series  of  cases  operated  on  by  one  or  other  of  the 
modifications  of  the  cesarean  section  have  been  very  suggestive  of  the 
fact  that  they  may  offer  increased  safety  to  the  patient  as  well  as  tend 
toward  a  more  comfortable  convalescence  even  in  clean  cases,  but  as  yet 
no  series  of  cases  large  enough  to  be  convincing  has  been  published,  since 
vt  is  a  well  known  fact  that  a  number  of  surgeons  have  performed  the 
classical  operation  successfully  on  series  of  a  hundred  or  more  patients 
without  mortality,  only  to  meet  with  misfortune  eventually.  Time  alone 
can  show  the  true  merits  of  the  newer  operations  and  whether  they  de- 
serve a  permanent  place  among  obstetric  operations. 

It  is  natural  that  most  of  the  pioneer  work  in  developing  the  extra- 
peritoneal operations  should  have  been  done  in  Europe,  owing  to  the 
conditions  under  which  obstetric  practice  is  carried  on  in  most  of  the 
European  countries,  where  the  majority  of  parturient  women  are  cared 
for  by  midwives,  who,  while  they  may  be  carefully  trained  in  the  aseptic 
care  of  normal  childbirth  and  the  convalescence  following  it,  are  not  well 
trained  in  the  study  of  the  pelvis  and  in  prenatal  work.  The  average 
patient  is  allowed  to  go  into  labor  without  any  attempt  being  made  to 
ascertain  in  advance  whether  any  disproportion  exists  between  the  child 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      153 

and  the  pelvis,  and  her  needs  are  only  discovered  as  a  general  rule  when 
labor  fails,  and  after  repeated  vaginal  examination  under  relatively  poor 
asepsis  a  medical  consultant  is  summoned.  I  say  "relatively  poor  asepsis" 
because  my  personal  experience  leads  me  to  believe  that  the  asepsis  of  the 
continental  surgeons  does  not  compare  favorably  with  that  of  American 
surgeons,  and,  therefore,  no  matter  how  well  trained  a  midwife  may  be 
in  other  respects,  her  asepsis  cannot  be  first  class.  It  is  a  fact  that  in 
Germany,  at  least,  the  development  of  fever  during  labor  is  one  of  the 
legal  requirements  which  necessitates  a  medical  consultation.  This,  of 
course,  means  in  many  cases  that  infection  of  the  uterus  has  already  oc- 
curred, and  if  cesarean  section  is  performed  by  the  classical  method  under 
these  conditions,  the  mortality  is  sure  to  be  high.  The  bad  results  necessi- 
tated by  such  a  routine  naturally  led  to  the  trial  of  various  expedients,  in 
the  hope  of  developing  an  operative  procedure  which  would  improve  the 
statistics  materially  and  thus  greatly  extend  the  field  for  abdominal 
delivery  by  increasing  the  safety  of  the  patient.  One  method  after 
another  has  been  tried  with  varying  degrees  of  success,  until  finally  two 
distinct  types  of  operations  have  been  developed,  either  of  which,  in  the 
hands  of  its  advocates,  shows  distinct  promise,  but  neither  of  which  has 
yet  been  proven  to  fulfill  all  that  has  been  hoped  for  it. 

Up  to  the  present  time  no  method  has  been  devised  by  which  a  child 
can  be  removed  by  an  abdominal  operation  with  entire  safety  to  the 
mother  from  a  uterus  which  is  already  infected  by  a  virulent  organism. 
Even  when  it  has  been  possible  to  reach  the  uterus  without  opening  the 
peritoneal  cavity,  infection  of  the  peritoneum  has  occurred  with  fatal  re- 
sults in  a  certain  number  of  cases  by  extension  from  the  uterus,  and  since 
it  is  very  common  for  the  peritoneal  cavity  to  be  opened  in  spite  of  all 
precautions,  direct  infection  is  even  more  liable  to  occur.  It  is  still  too 
early  to  predict  with  accuracy  what  the  final  status  of  this  operation  will 
be,  but  it  is  doubtful  if  it  will  ever  supersede  cesarean  section  followed 
by  hysterectomy  in  the  patients  who  are  believed  to  be  frankly  infected 
at  the  time  of  operation,  although  Kiistner  reports  a  mortality  of  only 
two  in  112  operations  by  his  method,  and  states  that  at  least  one  half  of 
his  patients  were  in  such  condition  at  the  time  of  operation  as  to  render 
them  bad  risks  for  the  classical  cesarean  section. 

The  results  of  other  operators  are  less  satisfactory  than  those  re- 
ported by  Kiistner,  and  even  amputation  of  the  uterus  in  frankly  in- 
fected cases  gives  a  mortality  of  over  20  per  cent.  This  would  seem 
to  suggest  one  of  two  things,  either  that  the  cases  in  Kiistner's  series, 
though  doubtful  risks  for  classical  operation,  were  not  infected  with  a 
virulent  organism,  or  that  his  method  of  operation  has  very  distinct 


154  CESAREAN  SECTION 

advantages  over  the  ordinary  methods  employed  and  may  eventually 
prove  to  be  the  operation  of  election  for  doubtful  cases. 

In  cases  in  which  the  uterus  has  already  been  infected  by  a  virulent 
organism,  especially  the  streptococcus,  no  abdominal  operation  can  be 
expected  to  give  satisfactory  results.  In  such  cases  cesarean  section  is 
contra-indicated,  if  any  other  method  of  delivery  is  possible,  even  though 
it  may  involve  a  destructive  operation  on  a  living  child.  This  is  espe- 
cially true  since  experience  has  shown  that  in  many  cases  of  antepartum 
infection  the  placental  vessels  are  invaded  by  the  infecting  organisms  be- 
fore delivery  is  accomplished,  resulting  in  the  death  of  the  child  from 
septicemia  a  few  days  after  birth,  even  though  it  may  have  been  in 
apparently  good  condition. 

The  improvement  in  results  which  has  followed  the  abandonment  of 
curettage  as  a  routine  procedure  in  the  treatment  of  puerperal  infection 
by  the  streptococcus,  and  the  substitution  of  medical  for  surgical  treat- 
ment, is  suggestive  of  the  fact  that  the  manipulation  of  the  uterus  neces- 
sary to  the  performance  of  cesarean  section  by  any  method,  which  is 
not  followed  by  the  removal  of  the  uterus,  must  result  in  such  an  increase 
in  the  process  as  to  increase  the  mortality  greatly.  Furthermore,  the  open- 
ing up  of  extensive  raw  surfaces  for  infection  must  result  in  such  a  rapid 
spread  of  the  infection  as  to  make  cesarean  section  in  the  face  of  viru- 
lent infection  an  exceedingly  desperate  operation.  Removal  of  the  uterus 
under  these  circumstances  offers  the  best  chance  for  the  patient,  if  the 
abdominal  route  is  selected,  but  even  then  a  mortality  of  twenty  per 
cent  results. 

In  cases  of  infection  with  organisms  of  slight  or  moderate  virulence 
better  results  are  obtained  after  operation  by  any  method,  although  there 
is  little  doubt  but  that  the  classical  operation  will  give  worse  results  than 
extraperitoneal  section,  both  as  regards  mortality  and  morbidity,  and  in 
doubtful  cases  the  latter  operation  is  to  be  preferred,  unless  hysterectomy 
is  considered  desirable  for  any  reason. 

In  cases  in  which  there  is  no  evidence  of  infection  and  yet  the  patients 
have  been  in  labor  for  some  time  and  have  been  subjected  to  repeated 
vaginal  examination,  even  under  good  asepsis,  the  results  of  the  classical 
cesarean  section  are  only  fair,  the  morbidity  being  relatively  high  and 
the  mortality  showing  an  appreciable  increase  over  that  obtained  by 
operation  at  the  time  of  election,  and  an  extra-  or  transperitoneal  opera- 
tion, with  protection  of  the  peritoneal  cavity  against  infection,  may  well 
be  employed  as  promising  better  results. 

Taking  the  results  of  the  various  methods  together,  it  seems  fair  to 
conclude  that  in  patients  at  the  time  of  election  the  extraperitoneal  opera- 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      155 

tions  will  show  little,  if  any,  better  statistics  than  the  classical  opera- 
tion, and  excellent  results  will  be  obtained  by  either  method ;  that  in 
cases  of  low  grade  infection  or  doubtful  cases  the  results  from 
the  extraperitoneal  operations  will  be  distinctly  better ;  and  that  in  viru- 
lent infections  no  abdominal  operation  will  give  good  results,  but  that  on 
the  whole  the  best  results  will  be  obtained  by  hysterectomy,  the  uterus 
being  delivered  from  the  abdomen  before  being  incised  for  the  delivery 
of  the  child,  and  the  peritoneum  carefully  protected  from  contamination 
by  gauze  packing. 

Although  obstetric  patients  in  this  country  are  much  more  liable  to  be 
under  the  care  of  a  physician  than  of  a  midwife,  the  lack  of  appreciation 
of  the  importance  of  prenatal  study  and  selection  of  the  method  of  de- 
livery best  suited  to  the  patient  before  the  onset  of  labor,  is  so  wide- 
spread that  a  great  majority  of  the  patients  who  require  cesarean  section 
come  to  operation  in  little,  if  any,  better  condition  than  those  under  care 
of  a  midwife.  The  extraperitoneal  section  is  still  in  its  infancy  here 
and  many  cases  are  sacrificed  yearly  to  a  combination  of  the  lack  of 
prenatal  study  plus  ignorance  of  any  method  of  abdominal  delivery  except 
the  classical  operation,  the  operator  either  not  recognizing  the  dangers 
of  cesarean  section  on  unfit  patients,  or  not  being  willing  to  sacrifice 
a  child  for  the  sake  of  saving  the  mother  by  performing  craniotomy  on 
the  living  child. 

More  is  to  be  hoped  from  the  education  of  the  physicians  of  this 
countr}^  in  the  importance  and  methods  of  prenatal  study  of  the  patient 
than  in  any  other  one  field  in  obstetrics,  but  it  is  also  probable  that  edu- 
cation in  operative  technic  and  instruction  in  the  choice  of  operation 
applicable  to  the  given  patient  under  the  conditions  which  are  present 
would  largely  reduce  the  mortality  which  at  present  exists. 

Methods  of  Operation. — There  are  two  general  types  of  so-called 
extraperitoneal  operations  in  vogue  at  the  present  time.  One  is  intended 
to  be  a  true  extraperitoneal  operation,  although  the  peritoneum  is  often 
opened  by  mistake,  and  the  other  is  in  reality  a  transperitoneal  opera- 
tion, in  which  the  general  peritoneal  cavity  is  protected  from  infection 
by  suture  of  the  cut  margins  of  the  parietal  peritoneum  to  the  cut 
margins  of  the  uterine  peritoneum  before  the  infected  uterus  is  opened. 
The  latter  is  the  easier  method  and  will  be  found  quicker  and  more  sim- 
ple in  the  average  case,  but  the  former  undoubtedly  protects  the  peri- 
toneal cavity  more  completely,  and,  therefore,  should  show  better  results 
in  well  trained  hands.  The  poorlyntrained  surgeon  will  find  it  a  difficult 
and  unsatisfactory  procedure,  and  in  cases  of  infection  of  the  uterus 
by  a  virulent  organism,  even  the  uninjured  peritoneum  may  become 


156  CESAREAN  SECTION 

infected  by  extension  from  the  infected  uterus,  and  the  patient  die  of 
peritonitis,  although  the  peritoneal  cavity  has  not  been  opened.  This 
demonstrates  the  fact  that  no  method  of  abdominal  delivery  is  safe 
in  cases  of  virulent  infection  of  the  uterus,  and,  therefore,  in  these  cases 
abdominal  delivery  is  to  be  avoided,  if  delivery  can  be  otherwise  accom- 
plished, craniotomy  being  the  operation  of  choice  in  cases  in  which  no 
other  method  of  delivery  through  the  pelvis  is  possible,  even  though  the 
child  may  be  alive.  The  maternal  mortality  following  craniotomy,  even 
on  infected  cases,  is  less  than  that  following  any  other  abdominal  opera- 
tion under  similar  circumstances,  and  the  chances  of  the  child,  even  if 
delivered  by  cesarean  section  under  these  conditions,  are  rather  poor, 
many  children  dying  of  infection  a  few  days  after  birth.  Therefore, 
the  operator  should  not  consider  the  interests  of  the  child,  but  should 
perform  craniotomy,  if  the  pelvis  is  large  enough  for  the  delivery  of  a 
mutilated  child,  i.e.,  if  the  true  conjugate  is  above  5  centimeters. 

In  impossible  pelves  abdominal  delivery  is  necessary  and  in  these 
cases  supravaginal  amputation  or  total  hysterectomy  offers  a  better 
chance  for  the  mother.  This  limits  the  field  for  the  extraperitoneal 
operation  to  cases  which  belong  in  the  doubtful  class  and  to  those  in  whom 
the  conservative  operation  is  admittedly  safe. 

There  would  seem  to  be  little  or  no  advantage  in  the  extraperitoneal 
operation  when  performed  on  clean  cases,  although  its  advocates  claim 
a  more  comfortable  convalescence,  and  the  technic  of  the  classical  cesa- 
rean section  is  so  much  simpler,  while  the  operation  allows  the  surgeon  so 
much  greater  choice  in  the  completion  of  the  operation,  neither  hysterec- 
tomy nor  sterilization  being  possible  if  the  extraperitoneal  methods  are 
employed,  that  I  prefer  it  in  patients  who  are  operated  on  at  the  time 
of  election  or  who  are  felt  to  be  uninfected. 

This  would  seem  to  limit  the  field  for  the  extraperitoneal  operation 
to  cases  neither  known  to  be  infected  nor  known  to  be  clean,  but  who 
belong  in  the  doubtful  class.  In  this  group  should  be  included  patients 
who  have  been  for  a  long  time  in  labor,  on  whom  repeated  vaginal  exami- 
nations have  been  made,  especially  under  doubtful  asepsis.  It  also 
includes  patients  in  whom  the  membranes  have  been  ruptured  for  a  con- 
siderable length  of  time  and  patients  on  whom  attempts  at  delivery 
have  been  made,  even  under  good  asepsis.  In  other  words,  extraperi- 
toneal cesarean  section  is  indicated  in  patients  in  regard  to  whom  there 
is  some  suspicion  that  uterine  infection  may  be  present  but  who  show 
no  symptoms  which  definitely  point  to  its  existence,  if  the  child  is  in 
good  condition  and  shows  no  signs  that  its  vitality  may  have  been  com- 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      157 

promised  by  the  efforts  at  delivery  to  which  it  has  been  subjected, 
whether  spontaneous  or  operative. 

According  to  some  authorities  pubiotomy  is  preferable  in  doubtful 
cases  in  which  the  true  conjugate  of  the  pelvis  is  above  7  centimeters,  a 
rule  which  would  limit  the  extraperitoneal  indications  still  further,  but 
pubiotomy  is  an  operation  which  as  yet  has  not  been  enthusiastically 
received  by  most  obstetricians.  Further  experience,  however,  may  show 
that  it  is  a  more  satisfactory  operation  than  extraperitoneal  cesarean 
section  in  all  except  extreme  cases  of  pelvic  contraction,  if  no  suspicion 
of  infection  exists,  and  that  in  those  cases  only  will  extraperitoneal  sec- 
tion prove  the  operation  of  election. 

Although  the  extraperitoneal  section  was  first  advocated  by  Frank  in 
1907,  Nicholson  in  19 14  was  able  to  collect  some  twenty  modifications. 
This  in  itself  proves  that  no  one  technic  has  been  discovered  which  is 
agreed  on  by  all  operators  as  ideal  for  all  patients.  In  general  the  opera- 
tions may  be  divided  into  extra-  and  transperitoneal  operations. 

There  is  nothing  to  be  gained  by  describing  here  each  modification 
which  the  operation  has  undergone,  and  I  shall  merely  describe  what 
seem  to  me  as  the  most  satisfactory  procedures  of  each  type  yet  evolved. 

(i)  Extraperitoneal  Cesarean  Section. — Kustner's  modifica- 
tion of  extraperitoneal  section  has  given  very  satisfactory  results  on 
appropriate  cases,  its  originator  having  reported  112  cases  with  two 
deaths.  According  to  Kiistner,  one  half  of  the  cases  operated  on  were 
apparently  appropriate  for  the  conservative  operation,  and  the  remain- 
der were  of  such  a  nature  that  he  would  have  hesitated  to  perform  the 
classical  operation  on  them.  Two  deaths  in  56  doubtful  cases  is  a  very 
satisfactory  showing  and  suggests  that  the  operation  deserves  a  further 
trial. 

The  technic  of  the  operation  is  as  follows  :  The  patient  (who  should 
be  well  advanced  in  labor)  is  etherized  and  the  abdomen  prepared.  She 
is  then  placed  on  the  operating  table  in  the  Trendelenburg  position.  Unless 
the  bladder  is  distended  with  urine,  150  cubic  centimeters  of  sterile  salt 
solution  or  boric  acid  are  introduced  into  the  bladder.  A  vertical  incision 
is  made  just  outside  the  outer  border  of  the  left  rectus  muscle,  extending 
12  centimeters  upward  from  Poupart's  ligament.  The  deep  layer  of 
fascia  is  incised  with  care,  the  object  being  to  expose,  but  not  open  the 
peritoneum.  The  reflexion  of  the  peritoneum  from  the  abdominal  wall 
to  the  viscera  and  the  left  side  of  the  bladder  is  now  visible.  By  means 
of  scissors  and  gauze  dissection  the  left  side  of  the  bladder  is  dissected 
off  from  the  anterior  surface  of  the  lower  uterine  segment  and  drawn 
well  beyond  the  midline  by  a  retractor.     The  peritoneal   reflexion  is 


158 


CESAREAN  SECTION 


pushed  upward  as  far  as  possible  and  the  anterior  surface  of  the  lower 
uterine  segment  is  exposed  by  retractors.     An  incision  is  made  in  the 


Fig.  35. — Kustner's  Operation. 
Skin  incision. 


midline  and  the  child  is  extracted  by  forceps.  The  incision  in  the  lower 
uterine  segment  must  be  very  carefully  made,  owing  to  the  extreme 
thinness  of  this  portion  of  the  uterus,  it  being  never  more  than  a  few 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      159 

millimeters  thick,  as  any  carelessness  may  result  in  cutting  the  child. 
The  placenta  is  now  removed,  the  uterine  wound  is  closed  in  two  layers 
by  catgut  sutures,  and  the  abdominal  wall  is  closed  in  layers,  except  at 
the  lower  angle  of  the  incision,  a  small  gauze  drain  being  inserted  into 
the  deepest  part  of  the  wound. 


Fig.  36. — Kustner's  Operation. 

a,    Lower    uterine    segment;    b,    peritoneal    reflection; 
c,    bladder    drawn    toward    center. 

The  amount  of  hemorrhage  is  usually  not  excessive  and  is  easily  con- 
trolled. There  is  always  some  danger  of  injuring  the  bladder  and  of 
opening  the  peritoneal  cavity,  but  if  the  dissection  is  made  with  care 
neither  of  these  accidents  should  occur.  During  the  separation  of  the 
bladder  the  left  ureter  and  uterine  artery  are  visible  in  most  cases  and, 
therefore,  should  be  safe  from  injury,  but  carelessness  may  result  dis- 
astrously. The  employment  of  the  Trendelenburg  position  during  the 
operation  is  almost  imperative.     The  operation  can  be  performed  in  the 


i6o 


CESAREAN  SECTION 


ordinary  dorsal  position,  but  the  difficulties  are  so  much  increased  that 
neither  the  operator  nor  the  patient  has  a  fair  chance. 

This  operation  is  probably  the  best  of  the  extraperitoneal  methods, 
and  in  cases  in  which  the  propriety  of  the  classical  method  is  doubtful  it 
may  often  prove  of  value,  but  it  has  certain  definite  disadvantages.  It 
should  not  be  substituted  for  the  conservative  operation  in  clean,  cases 


Fig.  zT- — Kustner's  Operation. 
Incision  in  uterus  low  down. 

and  should  be  undertaken  only  by  well  trained  surgeons;  second,  the 
bladder  is  sometimes  injured,  even  in  trained  hands;  third,  the  wound 
must  always  be  drained,  and  if  infection  occurs,  the  patient  must  undergo 
a  prolonged  suppurative  process,  to  which  she  may  succumb,  or  as  a 
result  of  which  she  may  be  invalided  for  a  long  time;  and  fourth,  the 
extensive  adhesions  which  result  make  its  repetition  impossible  in  sub- 
sequent labors.  It  is,  therefore,  an  operation  only  to  be  done  when  the 
risks  of  the  classical  operation  seem  too  great  and  yet  the  patient  is  not 
frankly  infected  with  a  virulent  organism.     Its  employment  in  proper 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      i6i 


cases  may  result  in  limitation  of  the  number  of  cases  in  which  pubiotomy 
is  recommended  as  a  substitute  for  a  late  cesarean  section. 

Latzko's  Operation. — Although  Kiistner's  technic  seems  to  me  to 
offer  the  best  chance  of  reaching  the  lower  uterine  segment  without 
undue  risk  of  injury  to  the  bladder  or  of  infection  of  the  peritoneal 
cavity,  Latzko's  operation  is  considered  preferable  by  some  operators. 
In  this  procedure  the  abdomen  is  opened  either  by  a  transverse  or  longi- 


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Fig.  38. — Kustner's   Operation. 
Introduction  of  uterine  suture. 

tudinal  incision  just  above  the  pubes,  carried  down  to  but  not  through  the 
peritoneum.  The  peritoneum  is  now  separated  from  the  bladder  and 
pulled  up  out  of  the  pelvis.  The  bladder  is  separated  from  its  attach- 
ments to  the  lower  uterine  segment  by  gauze  dissection  and  pushed  to  the 
right.  The  vesico-uterine  fold  of  the  peritoneum  is  then  retracted  up- 
wards toward  the  umbilicus,  leaving  a  denuded  area  made  up  of  the 
lower  uterine  segment  and  upper  cervix,  a  median  incision  of  which 
affords  sufficient  room  for  the  extraction  of  the  child  with  forceps.  The 
placenta  is  then  extracted,  the  uterine  wound  sutured  in  two  layers  and 


i62 


CESAREAN  SECTION 


the  abdomen  closed.  Drainage  is  necessary  only  in  patients  believed 
to  be  infected  when  operation  is  undertaken.  The  operation  is  not 
usually  a  difficult  one,  since  in  patients  who  have  been  for  some  time 
in  labor  the  pelvic  peritoneum  can  usually  be  readily  separated  from  the 


Fig.  39. — Latzko's  Operation  (I). 
(From  De  Lee's  "Obstetrics,"  copyright  by  W.  B.  Saunders.) 

underlying  structures,  but  if  infection  of  the  pelvic  connective  tissue 
occurs  the  convalescence  will  prove  long  and  exhausting. 

Transperitoneal  Operations. — The  difficulties  of  the  true  extra- 
peritoneal operations,  even  in  expert  hands,  have  led  to  an  attempt  to 
devise  an  efficient  transperitoneal  operation  which  would  give  equally 
good  results  in  doubtful  cases.     The  theory  of  these  operations  is  that 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      163 

the  uterus  shall  be  reached  by  the  transperitoneal  route,  but  that  befor^ 
the  uterus  is  opened  the  peritoneal  cavity  shall  be  protected  by  suture  of 
the  uterine  peritoneum  to  the  parietal  peritoneum,  in  such  a  manner  as 
to  shut  off  the  general  cavity  from  contamination  by  the  uterine  con- 


FiG.  40. — Latzko's  Operation   (II). 

(From  De  Lee's  "Obstetrics,"  copyright  by  W.  B. 
Saunders.) 

tents,  or  protection  may  be  provided  in  some  other  manner,  as  by  gauze 
packing  or  by  clamping  the  cut  edges  of  the  peritoneum. 

The  principal  variations  in  this  operation  consist  in  minor  differences 
in  the  variety  of  incision  used,  both  in  the  abdominal  wall  and  peritoneum 
and  in  the  method  of  suture  at  the  completion  of  the  operation,  which  are 


i64 


CESAREAN  SECTION 


largely  details  of  minor  importance.  I  have  selected  Hirst's  modification 
of  the  technic  employed  in  the  Veit-Fromme  operations  as  a  fair  repre- 
sentative of  the  operations  of  this  type. 


Fig.  41. — Latzko's  Operation  (III). 
(From  De  Lee's  "Obstetrics,"  copyright  by  W.  B.  Saunders.) 

The  abdomen  is  opened  by  a  longitudinal  incision  from  slightly  be- 
low the  umbilicus  to  the  symphysis,  long  enough  to  permit  the  easy 
extraction  of  the  child.  A  longitudinal  incision  is  then  made  through 
the  visceral  peritoneum  of  the  lower  uterine  segment,  which  is  easily 
separated  from  the  uterus,  especially  after  several  hours  of  labor,  of  the 
same  length  as  the  incision  in  the  parietal  peritoneum.  The  edges  of  the 
cut  flaps  of  parietal  peritoneum  are  then  united  by  a  continuous  catgut 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      165 

suture  of  the  edges  of  the  uterine  peritoneum,  thus  cutting  off  the  peri- 
toneal cavity  from  the  field  of  operation,  unless  it  is  torn  into  during 
the  extraction  of  the  child.  A  longitudinal  incision  is  then  made  in  the 
lower  uterine  segment  and  upper  cervix  and  the  child  is  extracted  by 
forceps. 

In  the  Veit-Fromme  methods  the  peritoneal  flaps  are  clamped  until 
after  the  child  is  extracted,  when  they  are  sutured.     The  union  of  the 


Fig.  42. — Latzko's  Operation  (IV). 
(From  De  Lee's  "Obstetrics,"  copyright  by  W.  B.  Saunders.) 

peritoneal  flaps  not  being  water  tight  when  the  uterus  is  opened  the  opera- 
tion can  hardly  be  called  extraperitoneal,  but  the  late  suture  protects  the 
peritoneal  cavity  from  infection  during  the  convalescence  to  a  certain 
extent.  Unless  time  is  a  great  object,  the  Hirst  modification  is  a  distinct 
improvement. 

After  the  child  and  placenta  are  delivered,  the  incision  in  the  lower 
uterine  segment  is  closed  in  layers  and  the  peritoneum  closed  over  it. 
Some   operators  prefer  to   remove   the   stitches   closing  the   peritoneal 


i66 


CESAREAN  SECTION 


cavity  and  suture,  first  the  visceral  and  then  the  parietal  peritoneum,  as 
in  the  classical  operation,  but  this  would  seem  to  do  away  with  much  of 
the  advantage  gained  in  the  primary  closure  of  the  peritoneum  and  to 
increase  the  danger  of  infection.  The  suturing  together  of  the  two  peri- 


FiG.  43. — Latzko's  Operation  (V). 
(From  De  Lee's  "Obstetrics,"  copyright  by  W.  B.  Saunders.) 

toneal  sacs  in  the  midline  would  seem  to  be  the  more  logical  method,  and 
I  can  see  no  disadvantages  in  it. 

The  one  objection  to  this  method  of  operation  which  is  apparent  is, 
that  the  opening  in  the  peritoneum  is  often  not  large  enough  to  permit 
the  extraction  of  the  fetal  head  without  tearing,  thus  opening  the  general 
cavity,  and  this  accident  has  been  reported  several  times.     If  this  hap- 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      167 

pens,  the  advantages  of  this  method  are  largely  done  away  with,  since 
the  opening  into  the  peritoneal  sac  permits  easy  contamination  of  the 
peritoneum  as  a  whole.  This  is  to  be  prevented  by  making  as  large  an 
opening  as  possible  in  the  peritoneum,  and,  according  to  Hirst,  suturing 
the  peritoneal  layers,  as  above  described.  After  the  peritoneum  is  closed 
the  abdominal  wall  is  closed  without  drainage. 

This  method  of  delivery  possesses  certain  very  definite  advantages 
over  the  true  extraperitoneal  methods.  First  and  most  important  is  the 
ease  with  which  it  can  be  performed.     Any  surgeon  who  is  properly 


Fig.  44. — Hirst's  Operation   (I). 
Abdominal  incision. 

qualified  to  perform  a  classical  cesarean  section  can  do  this  operation 
when  it  seems  desirable,  a  fact  which  does  not  hold  true  of  any  of  the 
true  extraperitoneal  operations,  which  are  often  technically  difficult 
and  require  special  training  on  the  part  of  the  operator.  It  may  properly 
be  urged  that  cesarean  section  should  only  be  performed  by  thoroughly 
qualified  surgeons,  but  the  fact  must  be  recognized  that  there  are  in 
many  communities  surgeons  who  are  sufficiently  trained  to  perform  a 
classical  cesarean  section  in  emergency,  but  who  are  not  qualified  to  per- 
form a  more  complicated  operation.  It  is,  however,  unfortunately  true 
that  in  such  communities  the  need  of  a  primary  cesarean  section  is  sel- 
dom recognized  and  the  very  type  of  case  in  which  an  extraperitoneal 


i68 


CESAREAN  SECTION 


operation  would  be  indicated  in  skilled  hands  is  the  most  common.  This 
fact  renders  the  transperitoneal  section  the  operation  of  choice  in  such 
communities,  although  experience  may  eventually  prove  the  extraperi- 
toneal operation  to  be  the  better  in  proper  hands. 

Aside  from  the  technical  difficulties,  the  greatest  objection  to  the 
extraperitoneal  operations  lies  in  the  fact  that  the  bladder  is  not  infre- 
quently injured,  even  by  skilled  surgeons  accustomed  to  the  operation, 


Fig.  45. — ^Hirst's  Operation   (II). 
Incision  in  parietal  peritoneum. 

and  the  ensuing  complications  often  add  greatly  to  the  discomfort  of 
the  patient,  if  nothing  more.  This  danger  is  avoided  in  the  transperi- 
toneal operations  and  this  fact  must  be  counted  distinctly  in  their  favor. 
In  neither  type  of  operation  is  the  peritoneal  cavity  absolutely  safe  from 
contamination,  since  it  may  be  opened  accidentally  when  either  procedure 
is  carried  out  with  resulting  infection,  or  in  cases  of  virulent  infection 
of  the  uterus  peritonitis  and  death  may  result  from  extension  of  the 
infection  through  the  intact  peritoneum,  although  the  operation  may  have 
been  perfectly  performed.     Another  advantage  of   the  transperitoneal 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      169 

route  is  that  drainage  of  the  wound  is  unnecessary,  whereas  it  is  neces- 
sary in  the  extraperitoneal  operation  of  the  Kiistner  type,  and  perhaps 
after  the  Latzko  operation,  and  drainage  may  result  in  infection  of  the 
connective  tissue  of  the  prevesical  space  in  patients  who  might  other- 
wise escape  infection  and  result  in  a  prolonged  suppurative  process, 
which  may  result  fatally.  Furthermore,  the  extensive  adhesions  left 
after  the  Kiistner  operation  limit  its  application  to  a  single  operation, 


Fig.  46. — Hirst's  Operation  (III). 
Incising  visceral  peritoneum  over  lower  uterine  segment. 

an  objection  which  does  not  hold  true,  however,  in  the  Latzko  operation. 
Finally,  if  it  is  desired  to  render  future  pregnancies  impossible,  steriliza- 
tion can  only  be  performed  at  a  second  operation. 

In  the  transperitoneal  method  the  operation  may  be  repeated  in  sub- 
sequent pregnancies  if  desired,  and  if  it  is  thought  best  to  sterilize  the 
patient  without  removing  the  uterus,  this  can  be  done  before  the  visceral 
peritoneum  is  opened,  which  obviates  a  second  operation  for  this  pur- 
pose and  adds  nothing  to  the  risk  of  the  operation.  This  contingency  is 
hardly  liable  to  arise,  however,  if  the  operation  is  limited,  as  I  believe 
it  should  be,  to  those  cases  which,  though  not  frankly  infected,  are  con- 


170 


CESAREAN  SECTION 


sidered  poor  risks  for  a  classical  operation.  In  these  cases  the  best  pro- 
cedure, if  sterilization  is  considered  advisable,  is  supravaginal  amputation 
of  the  uterus,  since  there  is  no  advantage  to  the  patient,  except  that  of 
retaining  the  menstrual  function,  in  sterilization  by  a  method  which 
leaves  behind  a  probably  infected  uterus  to  act  as  a  possible  source  of 


Fig.  47. — Hirst's  Operation   (.IV). 

Uniting  parietal  and  visceral  flaps  to  close  off  peritoneal  cavity  before 
incising  lower  uterine  segment. 

peritoneal  infection  and  death,  and  the  patient's  desire  to  retain  the 
menstrual  function  should  have  no  weight  in  the  decision,  unless  the 
uterus  is  known  to  be  uninfected,  or  at  least  believed  to  be  so. 

Neither  operation  is  suitable  for  frankly  infected  cases,  since,  if  the 
infective  organism  is  virulent,  the  danger  of  peritoneal  infection  is 
serious,  even  though  the  general  cavity  is  protected,  and  the  risk  to  the 
patient  in  suturing  the  uterus  and  returning  it  to  the  abdomen  to  act  as  a 
source  of  infection  is  too  great  to  be  considered.     Hysterectomy  is  the 


EXTRA-  AND  TRANSPERITONEAL  CESAREAN  SECTIONS      171 

only  proper  operation  in  these  cases  and  should  always  l^e  performed 
when  cesarean  section  is  necessary  in  frankly  infected  cases,  although 
in  patients  who  are  in  such  poor  condition  when  operation  is  undertaken 
that  it  is  feared  the  shock  of  hysterectomy  may  be  fatal  Sellheim's  opera- 
tion may  be  done.  In  this  procedure  the  uterine  incision  is  not  closed, 
but  the  margins  are  sutured  to  the  skin  edge,  producing  a  uterine  fistula 
which  may  be  left  open  indefinitely  or  closed  at  a  subsequent  operation, 
when  the  septic  infection  has  been  overcome.  A  very  limited  experience 
with  this  operation  has  convinced  me  of  its  value  in  the  type  of  case  above 
mentioned,  and  there  is  reason  to  believe  that  it  may  prove  a  satisfac- 
tory substitute  for  hysterectomy  in  a  certain  proportion  of  infected 
patients,  who  object  to  removal  of  the  uterus  because  they  hope  to  have 
other  children. 

The  principal  disadvantages  of  this  operation  are  that — the  infected 
uterus  not  being  removed — the  patient  must  first  overcome  the  septic 
process  and  then  at  a  later  date  be  subjected  to  a  secondary  operation 
for  closure  of  the  uterine  fistula.  Furthermore,  it  would  seem  probable 
that,  if  pregnancy  should  occur  at  a  later  date,  there  would  be  a  distinct 
danger  of  rupture  of  the  uterus  during  pregnancy,  which  might  prove 
fatal. 

There  are  certain  types  of  patients  for  whom  the  classical  cesarean 
operation  is  preferred,  even  by  the  most  ardent  advocates  of  the  extra- 
peritoneal operations.  Whenever  speed  is  an  object  the  classical  cesarean 
section  should  always  be  selected.  Therefore,  if  the  child  is  believed 
to  be  in  any  but  first  class  condition,  the  quickest  method  of  delivery 
should  be  selected.  In  cases  in  which  the  mother  is  in  doubtful  condition 
for  a  prolonged  operation,  as  for  instance  in  cardiac  cases,  or  in  cases  of 
premature  separation  of  the  normally  situated  placenta,  the  most  rapid 
method  should  be  selected.  In  cases  of  placenta  previa  the  increased 
vascularity  of  the  lower  uterine  segment  renders  high  incision  prefer- 
able and  the  extraperitoneal  operations  have  no  place.  In  most  other 
conditions  the  choice  of  operation  depends  on  the  personal  preferences  of 
the  operator,  and  in  clean  cases  with  no  suspicion  of  infection  I  am  satis- 
fied with  the  results  of  the  classical  operation  and  can  see  no  reason  to 
change  to  an  extraperitoneal  operation. 

LITERATUEE 

DoDERLEiN.     Uber     Extra-peritonealen     Kaiserschnitt.       Monschr.     f. 

Gebh.  u.  Gyn.     191 1.    33:  i. 
Druskin,  S.  J.     Extraperitoneal  Cesarean  Section.     Jr.  Am.  Med.  A. 

May  2,  1814. 


172  CESAREAN  SECTION 

DuHRSSEN,   A.      Zwei   Weitere   Buddhageburten.      Berl.    Klin.      Aug., 

1910. 
Hirst,  B.  C.     The  Advantages  of  the  Suprasymphyseal  Extraperitoneal 

Cesarean  Section.     Am.  Jr.  Obst.     191 3.     v.  67. 
Kronig.     Transperitonealer,     Cervicaler    Kaiserschnitt.       In     Kronig- 

Doderlein  Op.  Gynak.     1912.     P.  879. 
Latzo.     Uber  den  Extra-peritonealen  Kaiserschnitt.     Zentrbl.   f.   Gyn. 

1909.     P.  275. 
PoLAK,  J.  O.     Transperitoneal  Celiohysterotomy.     Am.  Jr.  Obst.     1916. 

V.  74. 
Reynolds,  E.     The  Superiority  of  Primary  over  Secondary  Cesarean 

Sections.    Tr.  Am.  Gyn.  Soc.     1907. 


CHAPTER  XIV 

PRINCIPLES   GOVERNING   CHOICE   OF   OPERATION 

Objects  to  be  Sought  in  Any  Obstetric  Case— Prenatal  Study  of  Patient  and  Choice 
of  Method  of  Delivery  Best  Fitted  for  Individual— Age  of  Patient— Size  of 
Pelvis— Size  of  Baby— Advantages  to  Given  Patient  of  Various  Methods  of 
Delivery— Primary  Operation — Operation  After  Modified  Test  of  Labor — Bibli- 
ography. 

As  obstetrics  is  ordinarily  practiced,  it  is  assumed  that  every  preg- 
nant woman  is  a  good  risk  for  childbirth  until  symptoms  arise  which 
call  for  special  treatment,  and  these  symptoms  are  often  not  appreciated 
until  it  is  too  late  for  a  satisfactory  result  to  be  obtained.  For  the  best 
good  of  our  patients  every  woman  should  be  looked  on  as  abnormal 
for  childbearing  until  a  painstaking  examination  proves  that  her  interests 
will  not  suffer,  if  she  does  not  receive  special  care.  Then,  and  only 
then  should  she  be  treated  as  a  routine  case. 

The  question  which  must  always  be  answered  in  any  obstetrical  case 
is,  what  method  of  delivery  is  best  suited  to  the  needs  of  the  individual 
patient  when  all  the  circumstances  of  the  case  are  taken  into  consideration. 
In  deciding  this  question,  various  factors  present  in  the  individual  case 
must  be  given  due  weight,  since  the  problem  is  a  fundamental  one,  and 
the  lives  or  future  well  being  of  both  patients  may  depend  on  the  con- 
clusion which  is  arrived  at.  The  rights  of  both  mother  and  child  must 
be  considered  on  the  one  hand  and  the  various  obstetric  procedures  which 
are  possible  under  the  given  conditions  on  the  other,  and  the  choice  of 
procedure  made  to  ensure  the  best  results  possible  in  the  light  of  the 
obstetric  skill  which  is  obtainable  and  the  conditions  under  which  the 
patient  must  be  delivered. 

There  are  three  objects  to  be  sought  in  every  obstetric  case :  first,  the 
hfe  of  the  mother;  second,  the  life  of  the  child;  and  third,  the  health  of 
both  mother  and  child.  Any  result  which  falls  short  of  attaining  these 
objects  is  to  a  certain  extent  a  failure,  at  least  from  the  standpoint  of  the 
patient,  and  must  be  considered  as  such,  although  there  exists  in  every 
community  a  certain  number  of  women  to  whom  pregnancy  will  prove 
a  serious  menace,  and  who  will  suffer  severely  in  health  and  perhaps  lose 
their  lives,  unless  their  needs  are  recognized  and  the  pregnancy  is  ter- 
minated at  an  early  date.     These  patients,  who  may  be  classed  as  the 

X73 


174  CESAREAN  SECTION 

definitely  unfit,  must  be  treated  according  to  their  individual  needs  and 
the  pregnancy  must  be  ended  by  the  most  conservative  method  as  soon 
as  the  patient  can  be  classified,  and  future  pregnancies  must  be  forbidden, 
or  better  yet  made  impossible,  if  the  contra-indication  is  a  permanent  one. 
In  many  of  these  patients  abdominal  hysterotomy  and  sterilization,  even 
in  the  early  months  of  pregnancy,  ofifers  the  best  method  of  treatment,  the 
patient  being  delivered  and  protected  against  future  danger  from  the 
same  source  at  one  operation,  which  is  desirable,  if  such  a  course  of 
treatment  is  considered  safe  for  the  patient. 

Whenever  the  patient's  condition  is  such,  at  the  time  when  delivery  is 
decided  on,  that  an  abdominal  operation  is  not  considered  advisable,  the 
pregnancy  should  be  terminated  by  a  vaginal  operation  and  the  sterili- 
zation deferred  until  some  future  time,  in  the  hope  that  the  patient's 
general  condition  may  so  improve  in  the  interval  as  to  render  the  comple- 
tion of  the  procedure  possible  in  comparative  safety,  the  patient  being 
sterilized  as  the  best  means  of  protection,  and  in  fact  sometimes  appar- 
ently the  only  one.  Sterilization  to  avoid  the  dangers  of  a  possible  preg- 
nancy and  abortion  may  seem  radical,  especially  as  many  members  of  the 
medical  profession  take  the  ground  that  the  patient  herself  must  adopt 
such  measures  as  are  necessary  to  prevent  pregnancy  and  the  responsi- 
bility of  failure  shall  rest  on  her  and  her  husband.  Repeated  experience 
has  shown,  however,  that  in  a  certain  number  of  cases  the  ordinary  means 
of  prevention  fail,  and  the  physician  is  faced  with  the  responsibility 
of  repeated  abortion  or  of  sacrificing  his  patient,  if  his  medical  conscience 
does  not  permit  of  this.  In  my  opinion  neither  of  these  courses  is  justi- 
fiable, and  I  believe  that  whenever  pregnancy  is  forbidden  as  being  prob- 
ably fatal  for  the  patient,  the  only  rational  treatment  is  to  render  it  im- 
possible, provided  the  contra-indication  is  a  permanent  one. 

The  great  majority  of  women,  however,  are  perfectly  good  obstetric 
risks  and  can  safely  undergo  pregnancy  and  labor  as  long  as  they  are 
under  efficient  observation  and  can  receive  intelligent  care.  Every 
patient  should  be  carefully  studied,  however,  with  reference  to  her  indi- 
vidual needs  and  peculiarities,  so  that  nothing  may  be  overlooked  which 
may  further  her  interests  or  those  of  the  child.  It  is  a  fact  which  should 
never  be  lost  sight  of  that,  although  a  patient  is  apparently  perfectly 
normal  and  a  favorable  outcome  both  for  mother  and  child  may  be  con- 
fidently predicted,  abnormalities  may  arise  at  any  time  .which  require 
careful  attention  and  often  prompt  treatment,  if  a  successful  outcome  is 
to  be  attained.  Even  in  an  apparently  normal  case  the  attendant  must 
be  prepared  at  any  moment  to  depart  from  a  policy  of  watchful  waiting 
when  any  possible  advantage  may  be  gained  for  the  patient  by  such  a 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  175 

course,  and  he  must  not  be  committed  to  a  single  method  of  treatment 
for  all  patients,  but  must  be  prepared  to  meet  appropriately  any  situation 
which  may  arise.  Probably  more  harm  is  done  because  the  average 
physician  is  not  properly  qualified  to  recognize  and  meet  the  needs  of 
the  individual  case  and,  therefore,  treats  all  patients  according  to  his  own 
limitations,  than  by  any  other  single  factor  in  obstetrics.  This  inability 
to  depart  from  routine  practice  for  incipient  symptoms  often  results  in 
the  loss  of  the  golden  opportunity  for  the  patient,  and  renders  necessary 
difficult  operations  in  the  face  of  serious  abnormalities,  which,  if  recog- 
nized and  treated  early,  could  have  been  dealt  with  in  a  simple  manner 
without  danger  to  either  patient. 

Between  these  classes  of  patients  there  is  a  large  group  of  patients 
who,  for  one  reason  or  another,  are  relatively  unfit  for  the  burdens  of 
pregnancy  and  labor  and  who  must  receive  careful  and  intelligent  over- 
sight during  pregnancy  to  avoid  disaster,  since  if  their  needs  are  not 
recognized  early  and  met  adequately,  the  ultimate  result  will  be  more 
or  less  unsatisfactory.  At  the  time  of  labor  these  patients  must  be 
accorded  the  care  suited  to  their  individual  needs,  and  a  failure  on  the 
part  of  the  attendant  to  recognize  that  they  require  special  attention  is 
often  followed  by  an  unsatisfactory  recovery  from  the  strain  to  which 
they  have  been  subjected  and  more  or  less  prolonged  ill  health,  if  noth- 
ing worse.  These  are  the  patients  who  must  be  handled  with  the  great- 
est skill,  since  if  an  error  of  judgment  is  made  either  during  pregnancy 
or  in  the  selection  of  the  method  of  delivery  best  suited  for  them,  the 
result  of  the  pregnancy  will  often  prove  a  failure. 

The  modern  improvements  in  operative  technic  have  brought  thq 
obstetric  art  to  a  point  where  a  well  trained  obstetric  surgeon  need  no 
longer  hesitate  to  recommend  a  certain  course  of  procedure  to  a  patient 
for  the  reason  that  it  is  not  absolutely  necessary  in  his  opinion,  when 
it  is  the  wisest  course  to  pursue  and  promises  the  best  ultimate  results, 
even  at  the  cost  of  a  slightly  increased  immediate  risk.  Every  obstetri- 
cian of  experience  can  remember  patients  in  whom  the  end  results  have 
been  far  from  satisfactory  to  both  the  patient  and  himself;  and  yet  in 
the  care  of  these  cases  no  apparent  indication  existed  for  not  following 
the  traditional  obstetrical  rules,  but  he  failed  to  recognize  the  special 
conditions  which  called  for  unusual  treatment  in  the  given  case.  A  few 
such  experiences  are  enough  for  any  obstetrician  who  works  with  his 
head  rather  than  with  his  hands,  and  his  future  patients  should  benefit 
by  his  errors  of  judgment;  but  unfortunately  in  most  instances  the  un- 
fortunate result  is  considered  hard  luck  and  future  patients  gain  noth- 
ing.    From  the  standpoint  of  so  conducting  the  case  that  the  maternal 


176  CESAREAN  SECTION 

and  fetal  lives  were  preserved  the  results  have  been  successful,  but  w^e 
must  remember  that,  unless  the  mother  is  brought  through  her  labor  in 
such  a  condition  that  she  is  able  to  resume  her  ordinary  activities  within  a 
reasonable  time,  the  conduct  of  the  case  has  resulted  in  at  least  a  partial 
failure,  and  the  result  argues  an  error  of  judgment  on  the  part  of  the 
attendant,  if  not  a  lack  of  careful  observation  of  his  patient.  Errors 
of  judgment,  if  not  so  frequent  as  to  show  incompetence,  are  pardonable, 
but  carelessness  and  neglect  are  not. 

It  is  not  enough  that  the  patient  should  be  studied  from  the  stand- 
point of  whether  labor  is  possible  or  not,  by  determining  the  adaptation 
between  the  fetal  head  and  maternal  pelvis  in  deciding  on  the  proper 
course  of  treatment  in  a  given  case,  but  also  the  fitness  of  the  patient  to 
undergo  a  severe  strain,  whether  from  a  physical  or  nervous  standpoint, 
and  the  probable  effect  of  labor  on  a  patient's  after  life  must  be  esti- 
mated. The  relative  importance  of  the  child  in  the  individual  case,  the 
condition  of  the  mother's  soft  parts  with  relation  to  probable  injury, 
and  the  probable  effect  on  her  of  the  discomforts  attendant  on  such 
injury,  as  well  as  the  existence  of  any  organic  lesion  in  the  mother  which 
may  be  affected  adversely  by  the  strain  of  labor,  are  factors  which  enter 
into  the  problem  in  every  case.  All  of  these  factors  must  be  taken  under 
careful  consideration  before  the  date  of  labor  is  reached  and  the  wisest 
method  of  delivery  determined  on  for  each  individual  patient,  so  that  if 
an  operative  delivery  is  selected  in  preference  to  a  normal  labor,  as  offer- 
ing distinct  advantages  for  the  patient,  it  can  be  undertaken  at  the  time 
when  it  promises  the  most  nearly  ideal  results. 

If  labor  has  already  begun  before  the  question  of  the  best  method  of 
delivery  for  the  individual  patient  is  taken  under  consideration,  various 
other  factors  complicate  the  problem,  since,  although  a  certain  procedure 
may  be  ideal  at  the  time  of  election  in  a  given  case,  it  may  be  far  from 
such  under  the  conditions  present  when  the  problem  is  forced  on  the 
attendant,  and  only  absolute  necessity  may  warrant  it.  The  length  of 
time  the  patient  has  been  in  labor,  the  degree  of  progress  already  made 
as  compared  with  the  severity  of  labor,  and  the  patient's  reaction  to 
labor,  must  all  be  taken  into  account.  Physical  exhaustion  of  the  mother 
may  contra-indicate  an  operation  which  would  be  unquestionably  the 
most  satisfactory  for  the  patient  at  the  beginning  of  labor.  If  the  mem- 
branes are  unruptured,  the  number  of  vaginal  examinations  and  the 
probable  asepsis  which  has  been  observed,  as  well  as  the  condition  of  both 
mother  and  child,  must  have  serious  weight  in  the  decision.  If  the  mem- 
branes have  been  ruptured  for  some  time  and  vaginal  examination  has 
been  practised,  this  fact,  together  with  the  condition  of  the  uterus,  the 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  177 

presence  or  absence  of  a  constriction  ring,  and  the  degree  of  thinning 
which  the  lower  segment  of  the  uterus  has  undergone,  must  be  estimated 
in  choosing  the  safest  method  of  deHvery  for  the  patient.  When  mother 
and  child  are  in  good  condition  the  choice  of  operation  should  Ije  such 
as  to  conserve  the  interests  of  both,  except  in  the  occasional  case  when 
preservation  of  the  life  of  the  child  will  evidently  jeopardize  the  mother's 
life.  In  such  cases  the  method  of  delivery  should  be  chosen  which  will 
give  the  mother  the  best  chance,  even  though  it  may  carry  with  it  a 
serious  increase  in  the  danger  to  the  child  or  even  deliberately  sacrifice 
its  chances.  To  deliberately  choose  an  operation  for  the  sake  of  the  child 
which  will  add  materially  to  the  danger  to  which  the  maternal  life  is 
subjected  is  poor  policy,  for,  of  the  two,  the  mother  is  the  more  im- 
portant. Cases  may  arise  in  which  circumstances  may  seem  to  warrant 
such  a  course,  but  it  should  never  be  undertaken  without  a  full  explana- 
tion of  the  conditions  which  call  for  a  decision  to  both  the  patient  and 
her  husband,  and  their  preferences  must  be  given  due  consideration. 

The  environment  of  the  patient  is  another  factor  of  considerable  im- 
portance. If  the  surroundings  of  the  patient  are  such  that  an  aseptic 
operation  can  be  performed  and  proper  after  care  provided,  the  choice 
of  operation  may  be  made  according  to  the  physical  findings  in  the  given 
case,  but  if  the  conditions  are  unsatisfactory  for  the  maintenance  of 
proper  asepsis,  an  abdominal  operation  which  would-be  advisable  under 
other  circumstances  should  be  abandoned  without  hesitation,  if  any 
other  method  of  delivery  can  be  undertaken  with  a  reasonable  chance 
for  the  mother,  even  though  it  may  involve  the  sacrifice  of  the  child. 
Unfortunately  most  operators  can  only  see  one  course  of  treatment  to  be' 
followed  in  doubtful  cases  and  the  patient  does  not  receive  intelligent 
study  before  this  course  is  adopted,  with  the  result  that  cesarean  section 
in  general  practice  is  attended  by  such  a  high  mortality  as  to  render  it  an 
unjustifiable  procedure  in  many  communities,  whereas  a  careful  con- 
sideration of  all  the  factors  present  in  the  individual  case  would  result 
in  greatly  increased  safety  for  the  mother  at  a  moderate,  increase  in  fetal, 
mortality. 

When  a  patient  Is  under  observation  during  pregnancy  there  are 
usually  several  methods  of  delivery  possible  in  the  average  case,  and  the 
patient  should  be  carefully  studied,  in  order  to  ascertain  which  method 
promises  the  best  results  under  the  given  circumstances,  the  decision  as 
to  the  course  to  be  adopted  being  made  before  the  patient  goes  into  labor, 
if  possible,  subject  to  change,  should  conditions  seem  to  warrant  it  l3efore 
serious  complications  arise.  In  the  great  majority  of  cases  it  is  pos- 
sible to  classify  the  patient  more  or  less  accurately  after  careful  examina- 


178  CESAREAN  SECTION 

tion,  especially  under  anesthesia,  although  it  may  not  always  be  possible 
to  say  whether  pelvic  delivery  is  possible  or  not.  It  is  usually  fairly 
easy  to  ascertain  whether  the  presenting  part  and  the  pelvis  bear  a  proper 
relation  to  one  another,  since  the  pelvis  can  be  measured  and  the  size  of 
the  child  more  or  less  accurately  estimated,  and  then  the  method  of  de- 
livery will  depend  on  the  estimated  character  of  the  labor,  the  probable 
resistance  of  the  patient  to  the  strain  of  a  not  unduly  difficult  labor,  the 
effect  of  pain  on  a  nervous  organization  which  is  more  or  less  definitely 
abnormal,  the  desirability  of  avoiding  all  strain  in  the  given  case,  and  the 
probable  risk  to  the  baby  if  labor  is  attempted. 

In  a  certain  number  of  cases  even  the  best  trained  obstetrician  will 
be  in  doubt  as  to  the  wisest  course  to  pursue,  and  may  feel  it  best  to  per- 
mit the  patient  to  go  into  labor  for  a  few  hours  and  observe  progress, 
as  well  as  the  reaction  of  the  patient  to  labor,  before  making  his  final 
choice,  the  labor  being  carefully  observed  and  preparations  made,  so  that 
the  indicated  treatment  may  be  carried  out  promptly  when  the  decision 
is  reached.  Such  a  course  gives  the  patient  the  advantage  of  every 
opportunity  for  careful  attention,  and  although  a  prolonged  test  of 
labor  renders  cesarean  section  more  dangerous  than  if  done  at  the  time 
of  election,  a  few  hours  of  moderate  labor,  the  progress  of  which  is  fol- 
lowed by  rectal  examination,  so  that  all  danger  of  vaginal  contamination 
is  avoided,  will  have  a  negligible  influence  and  does  not  eliminate  it  as  a 
proper  elective  procedure.  On  the  other  hand,  repeated  vaginal  exami- 
nations, or  an  attempt  at  operative  delivery  per  vaginam,  so  increase  the 
risks  of  abdominal  delivery  that  the  conservative  section  is  usually  contra- 
indicated  and  an  extraperitoneal  operation  should  be  performed,  if  the 
abdominal  route  is  preferable  for  other  reasons.  There  is  no  doubt  but 
that,  in  cases  in  which  the  true  test  of  labor  is  applied,  i.e.,  several  hours 
in  the  second  stage,  the  results  of  the  classical  operation  are  unsatisfac- 
tory. In  these  cases,  provided  no  evidences  of  uterine  infection  are  pres- 
ent, the  extraperitoneal  operation  promises  much  improved  results  and 
seems  to  be  the  operation  of  election. 

Every  obstetric  patient  should  be  considered  as  possibly  abnormal 
and  requiring  special  treatment  until,  after  careful  examination  and 
consideration  of  the  various  factors  present,  no  conditions  requiring  spe- 
cial treatment  can  be  found.  The  age,  physical  and  nervous  condition  of 
the  patient,  and  the  relative  importance  of  the  child  in  the  given  case, 
must  be  taken  into  account  as  well  as  the  relation  between  the  size  of  the 
child  and  the  maternal  pelvis.  The  probable  effect  of  a  difficult  labor 
on  the  future. health  of  the  mother,  as  well  as  the  probable  effect  of  pelvic 
injury,  must  be  taken  into  consideration  and  be  given  due  weight  in  de- 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  179 

ciding  what  is  the  wisest  method  of  effecting  dehvery  in  the  individual 
case,  since  although  both  mother  and  child  may  be  brought  through  alive, 
serious  invalidism  may  result  from  an  improper  choice. 

Several  courses  are  open  for  choice  in  the  great  majority  of  patients, 
if  intelligently  studied  in  the  last  few  weeks  of  pregnancy,  and  the 
method  of  delivery  to  be  employed  in  the  given  case  should  be  carefully 
selected,  with  not  only  the  immediate  result,  but  also  the  patient's  future 
welfare  in  view.  Of  course,  in  the  majority  of  patients  no  abnormality 
will  be  found,  of  sufficient  degree  at  least  to  call  for  any  special  treat- 
ment, and  the  patient  may  be  allowed  to  go  into  labor  with  every  expec- 
tation of  a  spontaneous  or  easy  operative  delivery;  but  it  must  l^e  re- 
membered that  labor  may  prove  unsatisfactory,  even  in  the  most  ap- 
parently normal  patient,  and  must  be  carefully  supervised  from  the  be- 
ginning, in  order  that  no  departures  from  the  normal  may  escape  detec- 
tion at  an  early  stage,  and  that  appropriate  treatment  may  ensure  a 
successful  outcome,  instead  of  an  emergency  operation  being  rendered 
necessary  when  the  patient  is  no  longer  in  good  condition.  On  the  other 
hand,  there  will  be  found  a  certain  number  of  patients  who  are  so  defi- 
nitely abnormal  in  some  way  as  to  require  special  treatment.  Patients 
who  show  a  definite  physical  abnormality,  whether  due  to  pelvic  dis- 
proportion, chronic  or  acute  disease,  or  whether  it  is  a  result  of  previous 
operative  procedures,  must  receive  special  study  and  the  method  of  de- 
livery be  carefully  adapted  to  their  individual  needs.  It  must  not  be  for- 
gotten in  these  patients  that,  although  a  normal  pelvic  delivery  may  be 
possible,  the  effect  on  their  after  health  may  be  such  as  to  leave  them  more 
or  less  seriously  invalided,  a  misfortune  which  might  and  probably  would 
be  avoided  if  the  proper  method  of  delivery  had  been  selected. 

In  the  same  category  belong  the  patients  with  a  lowered  nervous  re- 
sistance, to  whom  the  burdens  of  their  ordinary  life  are  all  or  more 
than  they  can  successfully  cope  with.  These  patients,  if  submitted  to  the 
strain  of  even  an  easy  labor,  may  become  chronic  invalids,  a  misfortune 
which  might  have  been  avoided  if  their  needs  had  been  recognized  and 
the  strain  of  labor  avoided. 

These  abnormal  patients  may  be  subdivided  into  several  groups,  ac- 
cording to  their  apparent  needs,  but  it  must  be  borne  in  mind  that 
although  a  given  patient  may  be  classified  as  accurately  as  possible,  cir- 
cumstances may  arise  which  will  call  for  a  complete  change  of  treat- 
ment at  any  period  of  labor,  and  the  most  careful  observation  must  be 
maintained  not  to  lose  the  golden  opportunity. 

According  to  the  estimated  degree  of  abnormality  in  the  given  case, 
several  courses  of  treatment  are  open :  ( i )  The  patient  may  be  allowed 


i8o  CESAREAN  SECTION 

to  go  into  labor  with  the  understanding  that,  if  progress  is  normal,  a  not 
too  prolonged  first  stage  will  be  permitted,  and  the  second  stage  ehmi- 
nated  by  a  prompt  operative  delivery  as  soon  as  cervical  dilatation  is  at- 
tained. It  must  be  understood,  however,  that  if  the  progress  of  labor 
proves  abnormal,  an  entire  change  of  policy  may  be  necessary  at  any 
time,  and  possibly  a  cesarean  section  selected  as  the  best  means  of  de- 
livery. This  method  of  treatment  will  prove  very  satisfactory  in  a  large 
group  of  subnormal  women,  in  whom  no  pelvic  disproportion  is  present; 
but  if  a  patient  who  in  other  respects  is  subnormal  comes  to  labor  with  an 
unengaged  presenting  part,  which  will  either  necessitate  a  prolonged 
second  stage  or  a  difficult  pelvic  operation,  she  should  be  reclassified  at 
once  as  a  poor  risk  for  a  pelvic  delivery  and  be  considered  as  a  proper 
risk  for  a  cesarean  section.  An  unengaged  presenting  part  in  a  primi- 
para,  who  is  in  other  respects  abnormal,  may  well  call  for  an  abdominal 
delivery,  even  though  examination  shows  that  no  serious  disproportion 
exists,  since,  the  patient  already  being  classified  as  a  doubtful  risk,  it  is 
unwise  to  subject  her  to  the  strain  of  a  labor  which  promises  to  be  of 
more  than  average  severity,  as  is  the  case  when  the  presenting  part  is  not 
engaged  at  the  beginning  of  labor. 

(2)  In  certain  doubtful  cases  where  the  patient  is  perfectly  normal 
except  for  a  slight  disproportion  between  the  pelvis  and  the  presenting 
part,  which  the  obstetrician  confidently  believes  will  be  overcome  by  the 
uterine  forces,  if  labor  is  satisfactory,  labor  may  be  permitted  under 
observation,  the  progress  being  followed  by  rectal  examination,  thus 
avoiding  vaginal  contamination  in  case  a  few  hours  of  labor  results 
in  little  progress  and  abdominal  delivery  seems  to  be  the  best  solution  of 
the  problem.  This  is  particularly  true  in  the  case  of  a  young  primipara 
in  whom  no  serious  pelvic  obstruction  can  be  made  out,  although  the 
presenting  part  remains  high  during  the  early  part  of  labor,  since  it  not 
infrequently  happens  that  a  relatively  difficult  primiparous  labor  may  be 
followed  by  easy  labors  in  subsequent  pregnancies,  and  in  a  perfectly 
healthy  girl  who  can  undergo  a  hard  labor  without  serious  after  effects, 
cesarean  section  should  be  undertaken  only  for  very  definite  indications, 
since  such  a  course  involves  a  similar  delivery  in  subsequent  pregnancies. 
In  such  a  patient  labor  may  be  allowed  to  go  on,  if  progress  seems  to  be 
normal,  in  order  to  mold  the  head  into  the  pelvis,  on  the  understanding 
that  a  pubiotomy  followed  by  forceps  or  version  may  possibly  be  neces- 
sary as  the  best  method  of  delivery  for  such  a  patient,  rather  than  a  late 
cesarean  section,  if  the  uterine  forces  are  not  sufficient  to  mold  the  head 
into  the  pelvis. 

(3)  In  other  cases  labor  may  be  permitted  for  a  few  hours,  in  the 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  i8i 

hope  that  a  short  trial  will  prove  that  the  physical  equipment  of  the 
patient  is  more  efficient  than  the  results  of  the  preliminary  examination 
would  warrant,  on  the  understanding  that,  if  the  results  are  anything  but 
perfectly  satisfactory,  a  complete  change  of  policy  will  be  made  and 
the  patient  delivered  by  cesarean  section,  whether  classical  or  extraperi- 
toneal, according  to  the  time  of  rupture  of  the  membranes  and  the 
amount  of  vaginal  interference,  etc.,  which  has  been  resorted  to. 

(4)  The  performance  of  an  elective  cesarean  section  is  the  method 
of  choice  in  all  cases  in  which  the  outcome  of  labor  is  considered  seriously 
doubtful,  whether  from  the  standpoint  of  maternal  health,  or  of  fetal 
life.  Undoubtedly  the  adoption  of  this  policy  will  result  in  a  few  un- 
necessary operations,  even  in  the  most  careful  hands,  but  the  results 
obtained  in  the  preservation  of  fetal  life  and  maternal  health  for  the 
many  will  more  than  counter-balance  the  unnecessary  operations  which 
result  from  an  occasional  error  in  judgment.  The  present  status  of 
cesarean  section  is  such  that,  under  proper  conditions,  a  favorable  result 
may  be  confidently  predicted  when  the  operation  is  undertaken  at  the 
time  of  election.  On  the  other  hand,  the  results  of  labor,  when  definite 
disproportion  exists  between  the  child  and  the  pelvic  canal,  are  relatively 
unsatisfactory,  both  for  the  life  of  the  child  and  the  after  health  of  the 
mother,  since  a  difficult  operative  delivery  often  results  in  such  serious 
injury  to  the  maternal  tissues,  even  if  otherwise  successful,  as  to  more 
or  less  seriously  invalid  the  patient.  Under  such  conditions,  although 
cesarean  section  may  not  be  absolutely  necessary  in  a  considerable  pro- 
portion of  cases,  it  would  seem  to  be  the  wisest  method  of  treatment. 

In  a  patient  whose  pelvic  measurements  are  normal,  or  only  slightly 
shortened,  and  little  disproportion  exists  between  the  child  and  the  pelvis, 
the  choice  of  the  method  of  delivery  to  be  adopted  depends  on  other  fac- 
tors. If  the  patient  is  apparently  in  sufficiently  good  physical  and  nervous 
condition  to  be  subjected  to  the  strain  incident  to  a  labor  of  rather  more 
than  moderate  severity  without  serious  after  effects,  even  though  she  may 
not  be  fully  up  to  the  normal  standard,  labor  may  be  permitted  under 
observation,  with  the  reservation  that,  if  her  powers  show  signs  of  failure 
before  the  completion  of  labor,  operative  interference  will  be  undertaken 
and  the  baby  delivered  by  forceps  or  version,  as  may  seem  best  at  the 
stage  of  labor  she  has  attained,  with  pubiotomy  or  even  craniotomy  as  an 
operation  of  last  resort  in  case  of  failure  of  delivery  by  the  ordinary 
methods.  It  is  almost  needless  to  say  that  no  obstetrician  would  be  justi- 
fied, under  modern  conditions,  in  deliberately  allowing  a  patient  to  go 
into  labor  with  the  prospect  of  a  possible  craniotomy  under  consideration 
before  labor  bejran:  Ijut  it  is  always  possible,  though  not  probable,  in 


i82  CESAREAN  SECTION 

these  patients  whose  equipment  is  somewhat  below  par,  that  circum- 
stances may  arise  during  labor  to  render  necessary  the  prompt  delivery 
of  the  child  to  save  the  life  of  the  mother;  and  unless  the  patient  is  in  a 
first  class  hospital,  which  might  warrant  a  change  of  policy  to  abdominal 
delivery  at  short  notice,  this  is  not  justifiable,  and  after  failure  to  deliver 
by  forceps  or  version,  craniotomy  may,  in  rare  cases,  be  indicated  for  the 
benefit  of  the  mother. 

In  patients  whose  general  physical  equipment  is  normal  but  in  whom 
a  moderate  degree  of  disproportion  exists  between  the  fetal  head  and 
the  pelvis,  labor  may  be  permitted  with  the  expectation  that  the  head  will 
mold  into  the  pelvis  and  permit  an  easy  extraction  from  below,  if  not 
a  spontaneous  delivery.  If  the  progress  of  labor  is  satisfactory  in  the 
early  hours  and  if  the  cervix  is  dilating  as  rapidly  as  it  should  for  the 
degree  of  energy  expended,  labor  may  be  allowed  to  go  on  until  the 
second  stage  is  reached.  If  after  a  reasonable  time  in  the  second  stage 
the  head  does  not  mold  into  the  pelvis,  even  though  neither  mother  nor 
child  should  develop  urgent  signs  of  distress,  the  question  of  delivery 
must  be  considered.  The  classical  cesarean  section  in  these  cases  does  not 
give  perfectly  satisfactory  results,  the  mortality  and  morbidity  both  being 
higher  than  at  the  time  of  election,  even  though  strict  asepsis  has  been 
observed  throughout  labor  and  rectal  examinations  have  been  substituted 
for  vaginal  examinations,  the  more  or  less  exhausted  patient  being  a 
relatively  poor  risk  for  abdominal  surgery.  The  choice  of  operation  in 
these  cases  lies  between  pubiotomy  followed  by  forceps  or  version,  extra- 
peritoneal section,  and  craniotomy  on  a  living  child.  The  last  named  pro- 
cedure should  not  be  considered,  unless  the  conditions  are  such  as  not 
to  warrant  the  belief  that  the  patient,  in  the  surroundings  in  which  she  is 
placed  and  with  the  surgical  skill  at  her  command,  will  have  a  fair  chance. 
If  the  surrounding  conditions  warrant  major  surgery,  the  choice  between 
pubiotomy  and  extraperitoneal  cesarean  section  will  be  made  according 
to  the  training  and  personal  preferences  of  the  individual  operator.  In 
the  hands  of  the  average  surgeon  extraperitoneal  section  will  probably 
give  the  best  results. 

I  do  not  wish  to  be  understood  as  advocating  allowing  a  patient  to  go 
into  labor  with  the  idea  of  performing  a  pubiotomy  or  extraperitoneal 
section,  as  I  distinctly  prefer  a  classical  cesarean  section  at  the  time  of 
election,  in  spite  of  the  claims  set  forth  by  the  advocates  of  the  extra- 
peritoneal operation;  but  in  cases  of  the  borderline  class,  with  a  pelvis 
whose  true  conjugate  is  between  9  and  10  centimeters,  and  the  child 
of  not  more  than  average  size,  the  results  of  labor  will  usually  be  satis- 
factory, and  if  all  of  these  patients  were  delivered  abdominally  at  the 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  183 

time  of  election,  a  great  deal  of  unnecessary  surgery  would  result  and 
much  harm  might  be  done.  It  is  only  in  the  occasional  case  that  the 
fetal  head  will  be  so  ossified  as  not  to  mold  deeply  enough  into  the  pelvis 
in  this  type  of  patient  to  permit  of  extraction  from  l^elow.  Failure  of  the 
uterine  forces  can  usually  be  recognized  after  a  few  hours  of  first  stage 
labor  at  a  time  when  good  results  can  be  expected,  if  it  is  decided  to  re- 
sort to  abdominal  delivery  after  a  moderate  test  of  labor.  If,  however, 
the  child  is  above  average  size,  as  showij  by  careful  examination,  or  if 
the  pregnancy  has  been  sufficiently  prolonged  beyond  the  expected  date 
to  warrant  the  assumption  of  overossification  of  the  fetal  skull,  the  pelvic 
measurements  cease  to  give  information  of  value,  and  the  relative  dis- 
proportion of  the  child  is  an  indication  for  an  abdominal  delivery  before 
or  early  in  labor.  Many  children  have  been  lost  through  close  adherence 
to  a  policy  which  insists  on  pelvic  delivery  whenever  the  pelvis  is  nor- 
mal, or  only  slightly  contracted.  The  important  factor  in  these  cases  is 
the  relation  of  the  individual  child  to  the  individual  pelvis,  plus  the  other 
factors  that  cannot  be  discovered  until  a  modified  test  of  labor  has  been 
applied.  If  the  child  is  overdeveloped,  it  furnishes  just  as  strong  an 
indication  for  cesarean  section  as  if  the  pelvis  is  contracted. 

If  in  patients  who  are  submitted  to  the  test  of  labor  progress  is  not 
satisfactory,  if  the  cervix  does  not  dilate  properly  under  the  pressure  of 
the  membranes,  or  if,  the  membranes  having  ruptured  prematurely,  the 
head  does  not  descend  deeply  enough  into  the  pelvis  to  produce  dilatation 
of  the  cervix,  the  test  of  labor  should  be  abandoned  promptly  and  thq 
patient  delivered  by  cesarean  section  before  exhaustion  and  possible  in- 
fection render  her  an  unfavorable  risk.  If  operation  is  undertaken  within 
a  few  hours  after  the  beginning  of  labor,  and  if  the  risk  of  vaginal  con- 
tamination is  slight  or  absent,  the  classical  operation  will  prove  satisfac- 
tory. Under  opposite  conditions  the  extraperitoneal  operation  will  give 
the  best  results. 

Whenever  a  patient  is  under  consideration,  in  whom  serious  doubt 
exists  as  to  the  possibility  of  pelvic  delivery,  on  account  of  marked  dis- 
proportion between  the  child  and  the  pelvis,  the  best  results  will  be  ob- 
tained by  the  classical  section  at  the  time  of  election.  This  will  result 
in  a  few  unnecessary  operations,  since  the  molding  power  of  the  fetal 
head  can  only  be  accurately  ascertained  by  a  prolonged  test  of  the  second 
stage  of  labor,  but  the  benefit  to  the  great  majority  of  patients  will  more 
than  compensate  for  this.  The  same  holds  true  in  patients  who  fall  well 
below  the  normal  standard,  whether  physically  or  nervously  in  whom 
the  strain  of  even  a  comparatively  easy  labor  may  produce  marked  after 
effects. 


i84  CESAREAN  SECTION 

Patients  with  marked  heart  lesions,  especially  mitral  stenosis,  or 
severe  aortic  lesions,  in  whom  the  previous  history  suggests  danger  of 
decompensation  during  labor,  or  in  whom  the  effect  of  labor  on  the 
future  health  of  the  patient  is  feared,  belong  in  this  group.  I  feel 
strongly  that  in  a  primipara  the  strain  of  labor  must  be  avoided.  In 
multiparae  with  soft  cervices  the  indication  is  less  clear,  unless  steriliza- 
tion seems  advisable,  as  is  the  case  if  the  patient  has  ever  had  an  attack 
of  decompensation.  Even  a  slight  test  of  labor  may  be  productive  of 
permanent  invalidism  in  these  patients,  who  are  in  the  unfit  class  for 
labor,  and  delivery  is  indicated  by  cesarean  section  at  the  time  of  elec- 
tion, in  order  to  minimize  as  far  as  possible  the  damage  to  the  heart, 
which  inevitably  results  from  pregnancy  and  which  will  be  much  in- 
creased by  labor.  The  classical  operation  is  best  suited  to  these  cases, 
since  it  is  quicker  and  easier  than  the  extraperitoneal  operations,  and, 
therefore,  is  less  likely  to  cause  shock  and  requires  a  shorter  period  of 
anesthesia,  and  furthermore  allows  an  opportunity  for  sterilization  if 
it  seems  advisable. 

In  other  patients  the  indication  for  operative  delivery  arises  from 
some  complication  of  pregnancy,  rather  than  in  some  deficiency  on  the 
part  of  the  patient  which  renders  her  a  subject  for  the  easiest  possible 
delivery.  Premature  separation  of  the  placenta,  placenta  previa,  and 
severe  and  threatening  toxemia  of  pregnancy  are  good  examples  of  this 
indication. 

The  time  of  operation  or  indication  for  delivery  is  determined  by  the 
threatening  nature  of  the  symptoms.  Whenever  the  symptoms  are  suffi- 
ciently threatening  to  indicate  prompt  delivery,  no  time  should  be  lost 
and  the  patient  should  be  delivered  as  soon  as  preparations  can  be  made. 
Unless,  however,  as  may  occur  in  certain  cases  of  hemorrhage,  delivery 
may  be  called  for  at  the  earliest  moment  possible,  the  patient  should  be 
removed  to  a  well  equipped  hospital  and  the  operative  procedure  under- 
taken with  due  deliberation,  since  hasty  operation  without  adequate 
preparation  may  result  in  saving  the  mother  from  death  by  hemorrhage, 
to  lose  her  from  infection. 

The  choice  of  method  depends  on  the  urgency  of  the  symptoms,  i.e., 
the  necessity  of  avoiding  all  possible  shock,  on  the  condition  of  the  soft 
parts,  on  the  period  of  pregnancy  which  has  been  reached,  and  on  the 
surroundings  in  which  the  operation  must  be  performed.  If  the  cervix 
is  long  and  rigid,  the  canal  not  obliterated,  and  the  patient  near  enough 
to  term  in  placenta  previa  or  eclampsia  to  warrant  hope  of  a  living  child, 
abdominal  cesarean  section  is  the  operation  of  choice. 

In  premature  separation  of  the  placenta,  although  there  is  little  or 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  185 

no  hope  for  the  child,  the  operation  is  indicated  on  the  mother's  account, 
since  her  condition  is  usually  such  as  to  render  the  avoidance  of  all 
possible  shock  advisable,  and  experience  has  proved  that  postpartum 
bleeding  may  in  any  case  render  hysterectomy  necessary.  In  a  certain 
proportion  of  these  cases  the  uterine  musculature  has  undergone  almost 
complete  disintegration  from  the  hemorrhage  which  has  taken  place  into 
it,  and  hysterectomy  offers  the  only  protection  to  the  mother  against 
death  from  postpartum  hemorrhage.  Delivery  from  below  in  these 
cases  is  too  long  and  difficult  a  process  and  attended  with  too  much 
shock  and  trauma  to  be  advisable,  the  patient  not  being  in  labor,  unless 
the  surroundings  of  the  patient  are  such  as  to  militate  against  success  if 
the  abdominal  route  is  selected.  If,  however,  in  placenta  previa  the  cer- 
vix is  soft  and  the  canal  obliterated,  so  that  the  stage  of  dilatation  will  be 
short  and  attended  with  little  shock,  and  especially  if  the  child  is  markedly 
small  and  premature,  the  use  of  a  dilating  bag  or  Braxton-Hicks  version 
after  partial  dilatation  of  the  cervix  will  give  on  the  whole  more  satis- 
factory results  for  the  mother,  while  the  prematurity  of  the  child  ren- 
ders its  prognosis  so  doubtful  that  it  should  not  be  considered  a  factor 
in  the  choice  of  operation. 

When  a  patient  is  first  seen  in  consultation  during  labor  the  need  for 
prompt  operative  delivery  is  usually  suggested  by  one  or  more  factors : 
( I )  The  presenting  part  is  not  engaged  after  several  hours  of  labor,  or 
is  only  lightly  engaged,  and  is  showing  no  tendency  to  enter  the  pelvis 
further,  in  spite  of  strong  uterine  contractions,  which  have  produced  a 
satisfactory  degree  of  cervical  dilatation.  Examination,  under  anesthesia 
if  necessary,  in  such  a  case  will  determine  whether  serious  disproportion 
exists  between  the  pelvis  and  the  presenting  part,  and  if  operative  de- 
livery seems  indicated,  the  method  best  suited  for  the  patient  can  be  se- 
lected after  a  careful  consideration  of  all  the  factors  in  the  given  case. 

(2)  In  spite  of  good  uterine  contractions  the  cervix  remains  thick 
and  rigid,  and  is  not  dilating  satisfactorily,  while  the  presenting  part  is 
showing  no  signs  of  entering  the  pelvis  and  signs  of  exhaustion  are  be- 
ginning to  appear.  Such  a  condition  shows,  either  that  the  uterine  forces 
are  insufficient  for  the  task  to  be  accomplished,  or  else  some  mechanical 
condition  is  present,  which  prevents  the  proper  application  of  the  forces 
developed  by  the  contractions.  In  either  case  there  is  little  or  no  chance 
of  spontaneous  delivery,  and  the  problem  to  be  settled  is  what  method 
of  operative  delivery  will  prove  most  satisfactory,  both  in  its  immediate 
and  remote  results.  If  conditions  are  otherwise  good,  cesarean  section 
in  such  a  case  is  probably  the  best  operation,  but  if  contra-indications  to 


i86  CESAREAN  SECTION 

this  are  present,  the  least  dangerous  method  of  pelvic  delivery  should  be 
selected, 

(3)  Alteration  in  the  rhythm  and  character  of  the  labor  pains, 
which  from  being  regular  and  of  good  character  become  irregular  and 
nagging,  commonly  associated  with  increasing  rigidity  of  the  uterus  as  a 
whole  and  marked  tenderness  over  the  lower  uterine  segment.  This 
sequence  suggests  uterine  exhaustion  and  calls  for  prompt  attention. 

(4)  The  early  appearance  of  signs  of  exhaustion  developing  on  the 
part  of  the  mother  or  child,  which  show  that  there  is  little  hope  that  the 
patient  can  accomplish  the  rest  of  labor  without  help,  even  though  prog- 
ress has  been  relatively  satisfactory  up  to  this  point,  and  operative  de- 
livery by  the  most  conservative  method  is  called  for. 

(5)  The  membranes  have  been  ruptured  a  considerable  time,  prog- 
ress is  unsatisfactory  and  the  patient's  pulse  and  temperature  are  begin- 
ning to  rise.  This  condition  is  always  suggestive  of  beginning  intra- 
uterine infection  and  an  abdominal  delivery,  unless  followed  by  an 
hysterectomy,  is  a  very  unwise  procedure. 

The  possibilities  of  operation,  under  these  various  conditions,  vary 
from  dilatation  of  the  cervix,  either  manually  or  by  the  use  of  a  dilating 
bag,  and  extraction  of  the  child  by  forceps  or  version,  to  delivery  by 
cesarean  section,  followed  by  removal  of  the  uterus  in  cases  in  which 
signs  of  infection  are  believed  to  be  present.  There  is  no  one  method 
applicable  to  all  cases  and  the  choice  of  operation  depends  on  the  judgment 
of  the  surgeon,  his  familiarity  with  the  various  procedures  possible,  and 
the  conditions  under  which  operation  must  be  performed. 

It  must  be  remembered  that  exhaustion  alone,  whether  uterine  or 
general,  has  a  distinct  influence  on  both  the  mortality  and  morbidity  of 
the  classical  cesarean  section,  that  every  vaginal  examination  which  has 
been  made  adds  to  the  risk  of  abdominal  interference,  and  that  the  less 
thorough  the  asepsis  the  greater  the  danger.  The  same  holds  true,  though 
to  a  much  less  degree,  of  the  extraperitoneal  operations.  Also,  it  must 
be  taken  into  consideration  that,  if  the  child  is  in  any  but  first  rate  condi- 
tion, no  avoidable  risks  for  the  mother  are  justifiable,  and  that,  even 
though  the  child  is  in  good  condition,  unless  the  surroundings  of  the 
patient  are  conducive  to  an  aseptic  operation  and  proper  after  care, 
cesarean  section  should  not  be  considered,  even  though  vaginal  delivery 
may  involve  the  death  of  the  child. 

In  all  cases  of  this  sort  the  patient  should  be  carefully  examined  un- 
der anesthesia,  if  necessary,  the  strictest  asepsis  being  observed.  The 
size  of  the  presenting  part  should  be  carefully  compared  with  the  pelvis, 
the  size  of  each  being  carefully  estimated.    The  degree  of  molding  which 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  187 

the  head  has  already  undergone  should  be  considered,  and  the  further 
degree  necessary  to  enable  it  to  pass  the  pelvis  estimated.  The  condition 
of  the  soft  parts  should  be  ascertained,  the  resistance  which  they  will 
oppose  to  delivery  estimated,  and  the  condition  of  both  mother  and  child 
determined.  If  the  cervix  is  fully  dilated  or  dilatable,  and  the  head  is 
engaged  in  the  brim,  a  tentative  application  of  high  forceps  may  be  made, 
to  test  whether  the  head  can  be  brought  into  the  pelvis.  If  the  head  ad- 
vances without  the  use  of  an  undue  amount  of  force,  this  method  should 
be  persisted  in  and  the  child  delivered.  If,  however,  the  tentative  trac- 
tion has  no  effect,  the  choice  of  operation  lies  between  extraperitoneal  sec- 
tion, pubiotomy  followed  by  forceps  or  version,  and  craniotomy,  the 
method  selected  being  dependent  on  the  condition  of  the  child  and  the 
question  of  uterine  infection  of  the  mother.  If  the  child  is  in  any  but 
excellent  condition,  or  if  the  mother  shows  signs  of  infection,  pubiotomy 
is  contra-indicated  and  craniotomy  offers  the  best  chance  for  the  mother. 
It  may  be  that,  in  a  case  of  this  sort,  the  family  may  demand  cesarean  sec- 
tion for  religious  or  other  reasons,  in  spite  of  the  danger  to  the  mother, 
and  in  this  case  either  an  extraperitoneal  section  may  be  performed,  if  no 
definite  evidences  of  uterine  infection  are  present,  or  a  supravaginal  am- 
putation of  the  uterus  following  cesarean  section,  if  such  evidences  are 
distinguished.  If  definite  evidences  of  probable  infection  are  present 
cesarean  section  by  any  method  offers  so  great  an  increase  in  the  danger 
to  the  mother  that  only  the  most  urgent  reasons  for  obtaining  a  living 
child  warrant  its  performance,  and  even  then  the  dangers  must  be 
thoroughly  explained  to  both  parents,  so  that  they  may  have  an  oppor- 
tunity to  decline  the  risk. 

When  examination  shows  that,  in  spite  of  prolonged  labor,  the  pre- 
senting part  is  not  engaged  and  the  cervix  is  still  largely  undilated  and 
rigid,  the  choice  of  operation  depends  on  the  estimated  disproportion  be- 
tween the  head  and  the  pelvis  and  the  condition  of  mother  and  child. 
As  a  general  rule  in  these  cases,  when  there  is  marked  disproportion  be- 
tween the  head  and  the  pelvis,  delivery  from  below  will  be  difficult,  both 
for  this  reason  and  on  account  of  the  rigid  undilated  cervix.  If  both 
patients  are  in  fair  condition  and  there  is  no  definite  evidence  of  infec- 
tion, an  extraperitoneal  cesarean  section  is  the  operation  of  election.  If 
the  child  is  in  poor  condition,  dilatation  or  incision  of  the  cervix,  fol- 
lowed by  craniotomy,  is  the  safest  procedure  for  the  mother,  unless 
there  is  evidence  of  a  virulent  infection,  or  the  pelvis  is  extremely  con- 
tracted, i.e.,  with  a  true  conjugate  of  less  than  5^  centimeters,  or  the 
child  is  unusually  large. 

If  in  such  a  case  there  is  definite  evidence  of  infection,  incision  of 


i88  CESAREAN  SECTION 

the  cervix  is  contra-indicated,  and  the  only  operation  which  offers  even 
a  fair  prospect  of  success,  in  case  the  cervix  is  too  rigid  for  manual 
dilatation,  is  cesarean  section  followed  by  removal  of  the  uterus,  and  at 
the  best  in  such  a  case  the  prognosis  is  doubtful,  the  mortality  being  in 
the  neighborhood  of  20  per  cent. 

In  frankly  infected  cases  the  best  chance  for  the  mother,  when 
marked  disproportion  exists  between  the  pelvis  and  the  presenting  part, 
is  cesarean  section  followed  by  hysterectomy,  unless  the  soft  parts  are  in 
such  a  relaxed  condition  as  not  to  seriously  compHcate  delivery  by  crani- 
otomy. Craniotomy  on  an  infected  patient  is  not  without  risk,  and  from 
8  to  10  per  cent  of  these  patients  die  as  a  result  of  the  infection.  In  the 
cases  which  require  a  difficult  manual  dilatation  or  incision  of  the  cervix, 
before  the  craniotomy  can  be  performed,  the  risk  is  much  greater  and 
abdominal  delivery  followed  by  amputation  of  the  uterus  is  probably 
safer  for  the  mother  and  offers  the  only  chance  for  the  child. 

It  is  impossible  to  consider  in  detail  all  the  complicating  conditions 
which  may  enter  into  the  problem,  but  this  brief  summary  will  serve  as 
a  general  guide  to  treatment.  A  routine  cesarean  section  in  all  late  cases 
of  complicated  labor  will  probably  prove  more  fatal  to  the  mother  than 
the  routine  adoption  of  any  other  single  method.  Many  lives  are  sacri- 
ficed yearly  because  cesarean  section  is  widely  adopted  as  the  easiest  way 
of  meeting  complicated  situations,  without  regard  to  the  fact  that  the 
prognosis  of  the  operation  grows  steadily  worse  with  every  hour  of  active 
labor  to  which  the  patient  is  subjected,  and  that  every  vaginal  examina- 
tion also  increases  the  risk,  even  though  the  asepsis  is  beyond  reproach. 
A  thorough  study  of  each  individual  patient  and  the  adoption  of  the 
method  of  delivery  best  suited  to  her  needs  and  the  circumstances  of  the 
case  will  do  much  to  improve  the  results;  but  as  long  as  the  majority  of 
obstetric  cases  are  cared  for  by  men  who  are  not  interested  in  obstetrics 
and  who  have  not  been  trained  in  the  care  of  complicated  labor,  the  re- 
sults will  never  be  satisfactory,  and  many  mothers  and  children  will  be 
sacrificed  unnecessarily.  Until  the  medical  profession  realizes  the  im- 
portance of  prenatal  care  and  is  willing  to  admit  that  no  man  can  do 
intelligent  obstetrics  unless  he  has  taken  special  training  to  fit  him  for  the 
work,  the  results  will  continue  to  fall  far  short  of  what  they  should  be. 
It  is  also  necessary  that  the  attendant  should  be  willing  to  admit  the  fact 
that  his  ability  to  perform  cesarean  section,  although  his  training  may 
not  be  sufficient  for  him  to  know  whether  cesarean  is  the  best  method 
of  delivery  for  the  patient  or  not,  is  not  a  sufficient  indication  for  sub- 
jecting the  patient  to  this  operation,  since  otherwise  cesarean  section  is 
almost  as  much  of  a  menace  to  the  parturient  woman  as  a  benefit. 


PRINCIPLES  GOVERNING  CHOICE  OF  OPERATION  189 

Extraperitoneal  cesarean  section  promises  well  in  cases  in  which  the 
classical  operation  seems  a  doubtful  expedient  on  account  of  the  dangers 
of  infection.  It  is  not,  in  my  opinion,  to  be  substituted  for  the  classical 
section  in  clean  cases,  although  future  experience  may  demonstrate  that 
it  has  very  definite  advantages,  except  when  speed  in  delivery  is  indicated 
for  any  reason,  or  when,  as  in  placenta  previa,  the  lower  uterine  segment 
is  so  vascular  as  to  render  a  low  incision  inadvisable. 


LTTERATUEE 

BuRCKHARDT,  C.  W.  H.     Ubcr  den  Werth  der  Verschiedenen  Methoden 

der  Sectio'  Caesarea.     Halle,  Karras. 
FiNDLEY.     Rupture  of  the  Scar  of  a  Previous  Cesarian  Section.     Am. 

Jr.  Obst.     1916.    74:411. 
Harris.     Results  of  the  Porro  Caesarean  Operation  in  All  Countries. 

Brit.  Med.  Jr.     1890.     1:68. 
Gerboud,    L.    J.      Des   differentes    incisions    uterines   dans    I'operation 

cesarienne  conservatrice.     These  de  Paris  No.  534.     1899. 
GuiLLET,  F.     L' operation  cesarienne  d'urgence.     These  de  Paris  No. 

330. 
HoLZAPFEL,  K.     Riickblick  und  Betrachtungen  iiber  die  Sectio  Caesarea 

Abdominalis  Inferior.     Sam.  Klin.  Vortr.  Gyn.     No.  196. 
NoRRis,  C.  C.     Intrapelvic  versus  Abdominal  Method  of  Dealing  with 

Mechanical  Obstruction  to  Delivery.     Tr.  Am.  Gyn.  Soc.   1908. 

33 '  182. 
PiNARD.     Indication  de  I'operation  cesarienne  en  rapport  avec  celle  de  la 

symphyseotomie.     Ann.  de  gyn.  et  d'obst.     1899.     52:  81. 
VooRHEES.     A  Report  of  Seven  Caesarean  Sections.     Am.  Jr.  Obst. 

1905.    52:161. 


CHAPTER  XV 

VAGINAL   CESAREAN    SECTION 

Vaginal  Hysterotomy  Better  Name  for  Operation — Indications — First  Three  Months 
of  Pregnancy — Second  Three  Months — Last  Three  Months — Technic  of  Operation 
— Bibliography. 

It  is  rather  unfortunate  that  the  term  vaginal  cesarean  section  should 
have  been  applied  by  common  usage  to  the  operation  which  is  better 
known  as  vaginal  hysterotomy,  since  this  misuse  of  the  name  cesarean 
section  sometimes  causes  a  certain  amount  of  confusion  in  regard  to  the 
nature  of  the  operation. 

True  cesarean  section  predicates  the  delivery  of  the  child  through  an 
incision  in  the  abdominal  and  uterine  walls,  and  the  operation  is  indi- 
cated in  patients  in  whom  some  condition  exists  which  renders  delivery 
through  the  pelvis  impossible  or  undesirable  for  one  or  both  patients. 

Vaginal  hysterotomy,  on  the  other  hand,  is  an  operation  by  which 
the  cervix  and  lower  segment  of  the  uterus  are  incised  per  vaginam  suffi- 
ciently extensively  to  remove  the  resistance  of  the  cervix  as  a  factor 
in  opposing  delivery,  which  must  then  be  accomplished  by  further  opera- 
tive means,  i.e.,  by  forceps,  version,  or  craniotomy,  according  tO'  the  in- 
dications in  the  given  case.  The  abdominal  cavity  is  not  opened  in  this 
operation,  except  by  mistake,  and  it  is  simply  a  procedure  to  secure  suffi- 
cient cervical  dilatation  to  permit  delivery,  which  must  be  accomplished 
by  some  other  operative  procedure. 

The  use  of  the  term  cesarean  section,  even  though  qualified  as  vaginal, 
leads  to  the  erroneous  supposition  that  the  two  operations  may  be  used 
interchangeably,  whereas  they  are  employed  in  entirely  different  classes 
of  patients  for  different  reasons,  and  the  fact  that  one  of  them  may  be 
indicated  in  a  given  case  practically  means  that  the  other  is  not  a  proper, 
procedure  under  the  conditions  which  are  present,  each  possessing  cer- 
tain advantages  under  certain  circumstances  which  renders  it  the  prefer- 
able operation  for  the  individual  patient. 

Indications  for  Vaginal  Hysterotomy. — Incision  of  the  cervix, 
rather  than  dilatation,  may  properly  be  employed  in  any  case  in  which  the 
necessity  for  delivery  is  urgent  and  the  cervix  is  too  rigid  to  permit  of 
rapid  manual  or  instrumental  dilatation  without  danger  of  serious  in- 

190 


VAGINAL  CESAREAN  SECTION  191 

jury  to  the  soft  parts,  or  when  the  attempt  to  induce  labor  by  the  use  of 
bougies  or  dilating  bags  has  been  made  and  proved  a  failure  and  the  symp- 
toms preclude  further  delay.  It  is  not  an  operation  of  election  in  patients 
in  whom  the  cervical  canal  is  obliterated  and  the  margins  of  the  external 
OS  are  not  rigid,  since  in  these  cases  manual  dilatation  is  ordinarily  a 
preferable  procedure ;  and  it  should  never  be  undertaken  in  patients  who 
are  supposed  to  be  infected,  since  in  these  cases  the  results  are  extremely 
bad,  owing  to  the  fact  that  the  extensive  wound  surfaces  produced  in  the 
operation  are  sure  to  become  infected,  exposing  the  patient  to  the  ex- 
haustion of  a  prolonged  septic  process,  and,  in  case  of  a  virulent  organ- 
ism, to  probable  death  from  the  increased  absorption. 

In  early  pregnancy  vaginal  hysterotomy  is  particularly  adapted  for 
use  in  cases  in  which  abortion  is  urgently  indicated  and  the  cervix  is  en- 
tirely unprepared  and  rigid.  This  will  be  found  particularly  true  in  pa- 
tients with  serious  heart  lesions  who  must  be  aborted  to  save  their  lives, 
and  in  patients  who  are  bleeding  to  a  dangerous  degree  and  in  whom  the 
rigid  cervix  renders  a  rapid  dilatation  impossible.  In  these  cases  the 
trauma  which  results  from  attempts  to  dilate  the  cervix  and  from  the 
prolonged  anesthesia  often  necessary  may  prove  the  final  factor  in  caus- 
ing the  death  of  the  patient,  whereas,  rapid  incision  of  the  cervix  and 
emptying  of  the  uterus  may  give  the  patient  a  chance  for  recovery. 

The  operation  is,  as  a  rule,  more  likely  to  be  necessary  in  primiparae, 
especially  in  women  with  long  conical  cervices,  the  dilatation  of  which 
may  prove  extremely  difficult  and  prolonged,  and  in  whom  the  use  of  the 
dilating  bag  is  apt  to  prove  unsatisfactory,  however  valuable  it  may 
prove  at  times  in  multiparae,  in  whom  the  cervix  is  rigid  on  account  of 
scar  tissue  resulting  from  laceration,  operative  procedures,  or  previous 
inflammations.  It  is  an  operation  which  is  ordinarily  easy  in  properly 
selected  cases,  but  it  is  not  suited  to  the  untrained  surgeon,  since  not  in- 
frequently it  is  an  operation  which  will  thoroughly  test  the  skill  of  the 
most  expert  surgeon,  especially  if  attempted  on  unfit  cases. 

It  may  be  called  for  in  early  pregnancy  in  cases  of  pernicious  vomit- 
ing, in  which  the  cervix  is  rigid  and  the  condition  of  the  patient  demands 
the  most  conservative  method  of  emptying  the  uterus,  i.e.,  the  method 
which  shall  produce  the  least  shock  and  the  shortest  period  of  anesthesia. 
If  the  cervix  is  at  all  rigid,  vaginal  hysterotomy  is  the  best  method  of 
securing  rapidly  the  necessary  degree  of  dilatation  to  permit  of  thorough 
emptying  of  the  uterus.  The  same  holds  true  for  other  conditions  which 
call  for  a  prompt  termination  of  pregnancy  in  the  early  months,  such  as 
cardiac  lesions  with  beginning  failure  of  compensation,  or  inevitable 


192  CESAREAN  SECTION 

abortion  associated  with  profuse  hemorrhage  in  a  patient  with  a  rigid 
cervix. 

Cervical  dilatation  by  the  ordinary  methods  in  cases  of  this  type  is  a 
long  drawn  out  process,  and  it  is  often  impossible  to  obtain  sufficient 
dilatation  by  them  to  permit  the  passage  of  the  finger  into  the  uterus  to 
remove  the  ovum,  and  in  cases  in  which  a  rapid  evacuation  of  the  uterine 
contents  with  the  least  possible  shock  is  advisable,  vaginal  hysterotomy 
may  prove  a  life  saving  operation. 

During  the  middle  three  months  of  pregnancy  the  indications  for 
vaginal  cesarean  section  are  practically  the  same  as  in  the  early 
months.  Any  condition  calling  for  prompt  delivery  in  a  patient  with  a 
long  rigid  cervix  will  be  more  successfully  treated  by  this  operation  than 
by  a  prolonged  difficult  dilatation  with  its  inevitable  trauma.  The  only 
-operation  which  comes  into  conflict  with  it  under  these  conditions  is 
abdominal  hysterotomy  followed  by  sterilization  in  patients  who  present 
a  permanent  contra-indication  to  pregnancy  and  labor,  such  as  severe 
heart  lesions  or  chronic  nephritis.  Since  repeated  abortion  is  not  to  be 
considered  in  such  cases,  an  operation  which  will  render  a  patient  sterile 
as  well  as  save  her  life  at  the  same  time  is  to  be  preferred  to  an  operation 
which  simply  ends  the  pregnancy,  if  the  condition  of  the  patient  is  such 
as  to  render  a  laparotomy  justifiable. 

During  the  last  three  months  of  pregnancy  prompt  delivery  may  be 
called  for  at  any  time  on  account  of  various  conditions,  especially  severe 
toxemia  which  does  not  yield  to  treatment,  placenta  previa,  premature 
separation  of  placenta,  or  cardiac  complications  with  failing  compensa- 
tion. Induction  of  labor  by  means  of  a  dilating  bag  or  abdominal  cesarean 
section  will  ordinarily  prove  to  be  the  best  methods  of  terminating  preg- 
nancy in  the  majority  of  such  cases,  the  choice  depending  on  the  esti- 
mated rigidity  of  the  cervix,  the  urgency  of  the  symptoms,  and  the  size 
of  the  child.  As  a  general  rule  in  patients  near  term,  in  whom  the  cervix 
is  long  and  rigid,  abdominal  section  will  give  the  best  results  for  both 
patients,  but  if  the  cervix  is  apparently  of  normal  consistency,  if  the 
child  is  markedly  premature,  and  if  the  symptoms  are  not  immediately 
urgent,  the  use  of  the  dilating  bag  will  prove  the  more  satisfactory.  If, 
however,  the  symptoms  are  too  urgent  to  permit  the  use  of  a  bag  on 
account  of  the  delay  involved  in  this  method  of  inducing  labor,  or  the 
child  is  more  than  six  weeks  premature  and  the  cervix  is  rigid,  vaginal 
hysterotomy  becomes  the  operation  of  choice.  It  is  also  to  be  preferred 
to  abdominal  delivery  in  cases  in  which  the  bag  has  been  employed  and 
found  ineffective,  since  the  danger  of  infection,  if  the  patient  is  delivered 
through  the  abdomen  after  the  intra-uterine  manipulation  necessary  to 


VAGINAL  CESAREAN  SECTION  193 

the  employment  of  a  bag,  is  so  great  as  to  practically  contra-indicate  the 
abdominal  operation,  unless  it  is  followed  by  hysterectomy,  and  in  these 
cases  vaginal  hysterotomy,  even  at  or  near  term,  becomes  the  operation 
of  election  for  the  trained  surgeon;  although  if  infection  of  the  uterus 
has  taken  place,  the  results  will  not  l>e  satisfactory,  and  no  cutting  opera- 
tion is  advisable,  if  other  means  of  accomplishing  delivery  are  possible. 

The  operation  becomes  more  difficult  the  nearer  to  term  the  patient, 
and  I  prefer  not  to  undertake  it  in  the  last  four  to  six  weeks  of  pregnancy, 
if  it  can  be  avoided.  Previous  to  that  time,  especially  before  the  child  is 
viable,  the  use  of  a  bag,  even  in  cases  with  fairly  marked  rigidity,  and 
vaginal  cesarean  section  in  case  the  bag  fails  to  produce  satisfactory  dila- 
tation, are  preferable  to  an  abdominal  delivery.  If,  however,  the  symp- 
toms are  too  urgent  to  permit  of  the  necessary  delay  appertaining  to  the 
use  of  a  bag,  the  choice  must  lie  between  vaginal  and  abdominal  cesarean 
section,  the  former  being  preferable  up  to  six  weeks  before  term,  and 
the  latter  in  the  last  month  of  pregnancy.  The  two  weeks  not  covered 
are  debatable  ground,  and  either  operation  may  properly  be  performed, 
according  to  the  judgment  of  the  individual  operator  and  the  conditions 
present  in  the  individual  case. 

Technic  of  Operation.  The  operation  of  vaginal  hysterotomy  was 
first  described  by  Diihrrsen  in  1896  as  a  better  procedure  than  the  divul- 
sion  of  the  cervix  by  means  of  the  Bossi  or  other  metal  dilator,  or  the 
difficult  manual  dilatation  of  a  rigid  undilated  cervix,  and  it  is  not  too 
much  to  say  that  time  has  justified  Diihrrsen's  claims.  The  vagina  is 
prepared  as  usual  for  operation  and  the  rectum  and  bladder  are  emptied. 
Full  anesthesia  is  necessary  for  a  successful  operation.  A  heavy  traction 
suture  is  then  introduced  through  either  side  of  the  cervix  which  is 
drawn  down  as  close  as  possible  to  or  even  outside  the  vulva,  or,  if  pre- 
ferred, the  traction  may  be  made  by  seizing  either  side  of  the  cervix  with 
a  French  hook,  though  this  method  is  more  likely  to  damage  the  cervical 
tissues  severely.  If  the  cervix  cannot  be  brought  down  to  the  vulva,  the 
difficulties  of  operation  are  much  increased.  A  longitudinal  incision  is 
then  made  through  the  anterior  vaginal  wall  from  a  little  above  the 
urethra  to  the  external  os  (Fig.  48).  The  bladder  is  then  separated  from 
the  anterior  surface  of  the  cervix  and  lower  uterine  segment  by  blunt 
dissection,  preferably  with  the  gloved  finger  covered  by  a  piece  of  gauze, 
at  first  by  touch  alone ;  but  later  a  large  retractor  is  introduced  into  the 
wound  and  the  separation  is  completed  under  the  guidance  of  the  eye. 
The  bladder  is  drawn  up  behind  the  retractor,  thus  exposing  the  whole 
anterior  wall  of  the  uterus  from  the  anterior  lip  of  the  cervix  to  the 
contraction  ring  with  a  pair  of  heavy,  straight  scissors.     A  median  in- 


ig4 


CESAREAN  SECTION 


cision  is  now  made  about  lo  centimeters  long,  extending  from  the  margin 
of  the  external  os  to  practically  the  level  of  the  contraction  ring.  The 
speculum  is  removed,  one  hand  is  introduced  into  the  uterus,  the  mem- 
branes are  ruptured,  and  the  child  turned  and  extracted.  If  the  child  is 
dead  or  non-viable,  it  is  a  wise  precaution  to  perforate  the  head  and 


Fig.  48. — Vaginal  Hysterotomy. 

thus  render  extraction  of  the  after  coming  head  more  easy,  since  the 
smaller  the  head  the  less  the  liability  of  damage  to  the  uterus  in  case  the 
incision  is  too  short.  The  placenta  is  extracted  manually  and  the  opera- 
tion is  completed  by  suturing  the  wound. 

Traction  on  the  sutures  introduced  at  the  commencement  of  the  opera- 
tion, or  on  the  French  hooks,  will  now  bring  the  whole  uterine  incision 
into  view  as  a  triangular  opening,  and  it  is  readily  closed  from  above 
downward  by  interrupted  sutures  of  chromic  catgut,  which  are  intro- 


VAGINAL  CESAREAN  SECTION 


195 


duced,  under  the  guidance  of  the  eye,  care  being  taken  to  place  the  upper- 
most stitch  just  above  the  upper  angle  of  the  wound.  The  incision  in  the 
vaginal  mucosa  is  then  closed  by  a  continuous  catgut  suture.  Some  op- 
erators prefer  to  introduce  a  small  rubber  drain  into  the  dead  space 
which  always  remains  between  the  bladder  and  the  vaginal  mucous  mem- 


FiG.  49. — Vaginal  Hysterotomy. 

brane,  to  prevent  the  formation  of  an  hematoma,  which  may  become  in- 
fected and  cause  symptoms.  This  is  usually  unnecessary,  however,  un- 
less there  is  free  venous  bleeding  present  and  it  is  not  possible  to  find 
and  ligate  the  bleeding  vessels. 

This  anterior  incision  afifords  sufficient  space  for  the  extraction  of  an 
average  sized  child  up  to  the  eighth  month  of  pregnancy,  but  after  that 
time,  or  in  case  of  an  unusually  large  child,  a  posterior  incision  should  also 
be  made.     In  this  case  the  operation  is  begun  by  a  transverse  incision 


196 


CESAREAN  SECTION 


to,  but  not  through,  the  peritoneum,  in  the  posterior  fornix  at  the  cervical 
junction,  the  peritoneum  being  peeled  off  from  the  cervix  and  lower 
uterine  segment,  which  is  then  incised  in  the  middle  line  for  a  distance  of 
5  centimeters,  after  which  the  anterior  incision  is  made  as  described. 
This  posterior  incision  is  necessary  in  cases  operated  on  near  term  to 


» 

i 

-^*'««w^ 

^9  *#^iB 

«    1^9 

f 

mi 

m 

f 

Fig.  so. — Vaginal  Hysterotomy. 

allow  room  for  the  passage  of  the  full  term  head,  the  smallest  circum- 
ference of  which  is  32  centimeters.  Otherwise  an  anterior  incision  of  15 
or  16  centimeters  would  be  necessary  to  permit  passage  of  the  head  with- 
out such  tearing  at  the  upper  end  of  the  incision  as  would  open  the  peri- 
toneal cavity.  With  the  double  incision  neither  need  be  so  long.  The 
posterior  incision  is  closed  first  and  then  the  anterior,  as  described  above. 
In  the  hands  of  a  trained  operator  this  operation  permits  delivery  of 


VAGINAL  CESAREAN  SECTION 


197 


the  child  in  a  few  minutes  and  the  whole  operation  can  be  completed  in 
thirty  minutes  or  less.  Aside  from  the  rapidity  with  which  the  operation 
can  be  performed  and  the  consequent  reduction  of  shock,  it  possesses 
definite  advantages  over  instrumental  or  manual  dilatation,  in  that  it 
leaves  a  clean  cut  wound  properly  united  by  sutures,  instead  of  a  deep 


Fig.  51. — Vaginal  Hysterotomy. 

irreguTar  cervical  laceration,  often  extending  into  the  lower  uterine 
segment,  which  it  may  prove  impossible  to  repair  properly.  If  the  in- 
cision is  carefully  made  in  the  median  line  the  amount  of  hemorrhage  is 
usually  very  slight,  but  if  the  incision  deviates  to  either  side  hemorrhage 
may  be  severe. 

The  ease  of  operation  is  distinctly  compromised,  if  the  speculum  em- 
ployed is  too  small  to  give  a  proper  view  of  the  field  of  operation,  or  if 
the  incision  is  too  short  or  not  in  the  midline  of  the  uterus.    In  the  latter 


198 


CESAREAN  SECTION 


case  the  hemorrhage  may  be  profuse,  owing  either  to  laceration  at  the 
upper  angle  of  the  incision  during  extraction  of  the  head,  or  to  injury 
of  the  large  vessels  which  lie  at  the  sides. 

There  is  a  distinct  tendency  to  relaxation  of  the  uterus  and  post- 
partum hemorrhage  after  the  operation,  and  it  is  distinctly  a  wise  pre- 


FiG.  52. — Vaginal  Hysterotomy. 


caution  to  pack  the  uterus  before  suturing  the  anterior  wall,  although  in 
many  cases  it  is  unnecessary. 

Diihrrsen's  suggestion  that  the  operation  could  be  made  more  simple 
and  easy  by  introducing  a  medium  size  dilating  bag  into  the  uterus,  which 
is  filled  with  sterile  saline  solution  and  used  as  a  tractor,  is  of  some  value 
in  difficult  cases.  This  acts  as  a  guide  to  the  length  of  the  incision  neces- 
sary for  the  delivery  of  the  child's  head,  the  anterior  wall  of  the  lower 


VAGINAL  CESAREAN  SECTION 


199 


Uterine  segment  being  incised  until  the  bag  slips  out,  thus  minimizing  the 
risk  of  attempting  to  deliver  through  too  small  an  opening. 

One  of  the  greatest  difficulties  in  the  operation  lies  in  the  fact  that,  in 
occasional  case,  it  is  impossible  to  bring  the  cervix  to  the  vulva,  and  if  the 
vagina  is  narrow  and  rigid,  this  may  render  the  operation  very  difficult, 


Fig.  53. — Vaginal  Hysterotomy. 

and  in  some  cases  the  perineum  must  be  incised  to  facilitate  the  operation. 
Ordinarily,  however,  it  is  a  simple  operation  for  the  trained  surgeon,  the 
great  difficulty  in  private  practice  being  that  it  requires  the  help  of  two 
assistants  besides  the  anesthetist,  as  well  as  a  good  light.  It  is,  therefore, 
not  well  fitted  for  use  by  the  general  practitioner  of  little  or  no  surgical  ex- 
perience, who  often  has  to  operate  without  trained  assistants  in  emer- 
gency cases,  as  was  recommended  by  Peterson  a  few  years  ago;  and 
furthermore,  its  success  depends  on  the  maintenance  of  thorough  surgi- 


200  CESAREAN  SECTION 

cal  asepsis.    It  is  distinctly  a  hospital  operation  for  a  trained  surgeon,  to 
be  undertaken  only  on  patients  believed  to  be  uninfected. 


LITEEATURE 

DuHRRSEN,  A.     Der  Vaginale  Kaiserschnitt.     Berlin :  1896. 

Die   Neue   Geburtshilfe  und  der  Praktische  Arzt.     Sam.    Klin. 

Vortr.     1909.     No.  549. 

KosMAK^  G.  W.  Vaginal  Cesarean  Section  and  its  Limitations.  Am. 
Jr.  Obst.      1912.     V.  65. 

Leciere,  L.  L'hysterotomie  vaginale  anterieure.  Paris,  191 2,  These 
de  Paris  No.  361. 

Mason,  N.  R.  Vaginal  Delivery  after  Cesarean  Section.  Bost.  Med. 
Surg.  Jr.     Jan.  25,  191 7. 

Peterson.  Indications  for  and  Technique  of  Vaginal  Caesarean  Sec- 
tion.    Surg.  Gyn.  Obst.     1909.    8. 

Stein,  A.  Vaginal  and  Abdominal  Cesarean  Section.  Am.  Jr.  Surg. 
Feb.,  1916. 


INDEX 


Abdominal  abortion,  definition  of,  82 

—  indications  for,  83 
Abortion,  abdominal,  82 
indications  for,  83 

Abscess   of   uterine   walls,    following 
Cesarean  section,  132 

Acute  appendicitis,  complicating  con- 
valescence, 137 

Acute  dilatation  of  stomach,  complicat- 
ing convalescence,  127 

Acute  infectious  diseases,  contra-indi- 
cation  to  elective  Cesarean 
section,  90 

Adhesions,  administration  of  ergot  in 
presence  of,  107 

Anesthesia,  general,  chloroform,  102 

ether,  103 

gas-oxygen,  103 

nitrous  oxide  gas,  102 

—  local,  103 
novocain,  103 

—  paravertebral,  104 

—  preparation  for,  by  morphin-scopo- 

lamin  sequence,  104 
by  plugging  ears  with  cotton,  105 

—  spinal,  104 

Anteflexion  of  the  uterus,  indicating 
Cesarean  section,  59 

Antiseptic  precautions,  following  Cesa- 
rean section,  124 

Appendicitis,  acute,  complicating  con- 
valescence, 137 

Atony  of  uterus,  indication  for  removal 
of  uterus,  145 

Atresia  of  the  generative  canal,  indi- 
cating Cesarean  section,  of  the 
cervix,  58 

of  the  vagina,  58 

of  the  vulva,  57 

Bischoff's  panhysterectomy,  6 
Bladder,  care  of,  after  Cesarean  sec- 
tion, 121 

—  tumors  of,  indicating  Cesarean  sec- 

tion, 57 


Bowels,  care  of,  after  Cesarean  section, 
121 

—  preparation  of,  for  operation,  98 

Carcinoma  of  the  cervix,  indicating 
Cesarean  section,  54 

—  indicating     complete     hysterectomy, 

54 

Cardiac  complications,  indicating  ab- 
dominal abortion,  83 

— 'indicating  Cesarean  section,  31,  74, 
184 

— ■  —  myocarditis,  ^(i 

— ■  —  valvular,  75 

—  indicating  laparotomy,  83 

— '  sterilization  of  patient  at  time  of 
Cesarean  section  in,  140,  141 

—  time  of  election  for  Cesarean  sec- 

tion in  presence  of,  96 
Catheterization,   question   of,   in   after 

care  of  operation,  121 
Cervix,   carcinoma   of,   indicating  Ce- 
sarean section,  54 
indicating  complete  hysterectomy, 

54 

—  cicatricial     stenosis     of,     indicating 

Cesarean  section,  58 
— •  dilatability  of,  as  a  sine  qua  non  of 
successful  pelvic  delivery,  26 
— 'dilatation  of,  116 
Cesarean  section,  as  an  abused  obstet- 
ric practice,  ii,  93 

—  after  care,  119 

'  antiseptic  precautions,  124 

of  bladder,  121 

of  bowels,  120 

— '  —  catheterization,  121 

'  complicated  by  abscess  of  uterine 

walls,  132 
— ■  —  —  by  acute  appendicitis,  137 
by  acute  dilatation  of  stomach, 

127 

'  —  by  embolism,  130 

-by  pneumonia,  129 

by  septic  conditions,  130 


202 


INDEX 


Cesarean   section,    after   care,    compli- 
cated     by    septic     peritonitis, 

134 

by  wound  infection,  136 

diet,  120 

distention  of  abdomen,  122 

lactation  and  nursing,  124 

lochia,  123 

pain,  119 

pulse,   126 

temperature,  125 

'thirst,  120 

•  —  ether,  1 03 

—  anesthesia     employed     in,     general, 

chloroform,  102 

■  —  gas-oxygen,  103 

nitrous  oxide  gas,  102 

local,  103 

novocain,  103 

—  —  paravertebral,   104 

preparation     for,     by     morphin- 

scopolamin  sequence,  104 

^by  plugging  ears  w^ith  cotton, 

105 

spinal,  104 

—  before  period  of  viability,  or  abdom- 

inal abortion,  82,  83 
■ —  choice  of  operation,  principles  gov- 
erning.     See   Principles   Gov- 
erning Choice  of  Operation. 

—  classical,  modifications  of,  to  elimi- 

nate disadvantages,  151 

positive  indications  for,  171 

procedure,  106 

relative  claims  of  intraperitoneal 

and,  9,   10,   154,   156 

—  complications  of  convalescence,   127 

abscess  of  uterine  vi^alls,  132 

'acute  appendicitis,  137 

acute  dilatation  of  stomach,  127 

embolism,  130 

—  —  pneumonia,  129 

—  —  septic,   130 

septic  peritonitis,  134 

w^ound  infection,  136 

—  danger  of,  12 
— •  definition  of,   i 

—  elective,  conditions  determining  de- 

gree of  danger  to  mother,  87 
contra-indications  to,  exhaustion, 

89 

in  cases  of  infection,  19 

intercurrent  diseases,  90 


Cesarean  section,  elective,  contra-indi- 
cations to,  on  patients  late  in 
labor  and  possibly  infected,  19 

premature  rupture  of  mem- 
branes, 88 

— ' previous  attempts  to  induce  la- 
bor by  bag  or  bougie,  or  at- 
tempts at  pelvic  delivery,  89 

repeated   examinations   during 

labor,  88 

■surrounding   conditions,   91 

'in  toxemias  of  pregnancy,  90 

—  uterine  infection,  87 

definition  of,  85 

distinguished   from  operation  "at 

the  time  of  election,"  85 

fundamental    principles    govern- 
ing, 86,  91,  92,  181 

— ■ surrounding  conditions,  91 

indications  for,  85 

—  extraperitoneal,  advantages  of  trans- 

peritoneal operation  over,  167, 
169 

'Comparison  of  advantages  and  re- 
sults of,  with  classical  opera- 
tion, 7,  9,  10,  154,  156 

— ■  — •  Frank's,  7 

— ' — ■  —  modification  of,  by  Latzko, 
Sellheim  and  others,  8 

— ' — 'general  types  of,  155 

greatest  objection  to,  168 

— • — 'history  of,  151,  157 

— '  —  indications  for,  156,  189 

— '  —  inefficient  in  infected  cases,  153, 
170 

— ■  —  Kiistner's  modification  of,  9 

• — ^  technique,  157 

disadvantages  of,  160 

Kiistner's  reports  on,  153 

— ' — •  Latzko's  operation,  8 

technique  of,  161 

methods  of,  155 

'modifications  of,  157 

'  —  Kiistner's,  157 

Latzko's,  8,  161 

Sellheim's,  8,  171 

— ■ — '  pioneer  work  on,  in  Europe,  152 

— ' — 'purpose  of,  151 

— ' — 'results  of,  7,  154 

from  reported  series  of  cases, 

152 

—  factors  militating  against  success  of, 

186 


INDEX 


203 


Cesarean  section,  followed  by  hysterec- 
tomy, indications  for,  19 

by    supravaginal    amputation    of 

uterus,  19,  88 

—  Frank's  operation,  7 
modifications  of,  8 

—  history  of,  Bischoff's  operation,  6 
conservative,   or   Sanger's   opera- 
tion, 6 

Doderlein's  laparo-elytrotomy,  8 

first  generally  accepted  perforu. 

ance     of,    by    Trautmann     of 
Wittenberg,  4 

first  popularity  given  to,  5 

first  use  of  sutures  in,  4 

Frank's  operation    (1907),   7 

modifications  of,  8 

Kronig's  operation,  9 

Kiistner's    modifications,    9;    See 

also  Kiistner's  Operation. 
modifications    of    Frank's    opera- 
tion, 8 

of  the  Porro  operation,  6 

monograph   on  subject  of  Fran- 
cois Rousset  in  1581,  4 
-~  —  mortality     recorded     in     second 
period  of,  5 

operation  on  the  dead,  2 

operation  on  the  living,  2 

operation    performed    by    Jacob 

Nufer,  in  1500,  3 

operation  witnessed  in  Uganda  in 

1879,  2 

origin  of  term,  i 

period  previous  to  1500,  3 

period  from  1500  to  1876,  3 

period  from  1876  to  1907,  5 

period  from  1907  to  date,  7 

— •  —  periods  covered  by,  3 

Porro's  operation    (1876),  5,   146 

modification  of,  6 

purpose  and  results  of,  144 

radical,  or  Porro's  operation,  5 

relative    claims    of   classical    and 

extraperitoneal    operation,    9, 
10,  154,  156 

revival  of  laparo-elytrotomy,  8 

Sanger's   operation    (1882),  6 

■ —  importance  of  carefully  supervised 
labor,  179 

of  prenatal  care,  174 

of  prenatal  examinations,  94 

of  prenatal  study,  152,  155 


Cesarean    section,    incision    for,    abdo- 
minal, high,  108 

— ■ location  of,  107 

— • — • — 'low,    108 

•  —  size  of,   108 

'transverse,  of  fundus,   113 

— • — -uterine,  no 

—  — • — 'in  lower  uterine  segment,   115 
— • suture  of,   113 

—  indications  for,  absolute,  85 
abuse  of,  11,  93 

— ■ — ^  after  operations  for  pelvic  repair, 

37 

'Cardiac,  31,  74,  184 

■ — 'myocarditis,  76 

'  —  valvular  lesions,  75 

— '  —  consideration  of,  as  an  operation 

of  choice,  52,  67 
— ' — 'in  doubtful  cases,  21 
— ' — '  —  importance  of  pelvic  examina- 
tion during  last  weeks  of  preg- 
nancy, 22 

' — impressing  head  into  pelvis  by 

Miiller's  method,  22 
— ' in   multipara  having  had  pre- 
vious obstetric  disasters,  24 
— ' — • — 'in  primipara  of  an  age  close  to 
end  of  child-bearing  period,  23 
— ' — 'in  eclampsia,  67 

in  elderly  primiparae,  78 

— '  —  as  an  elective  procedure,  85 

examination  of  pelvic  outlet,  34 

— ' — 'extension  of,  20 

factors  to  be  considered,  25 

'  —  cardiac  conditions,  31,  74,  184 

■ — dilatability  of  cervix,  26 

efifect  of  labor  on  patient,   30 

— moldingpower  of  fetal  head,  28 

^  probable  character  of  labor,  26 

— ■  —  as  a  health-saving  measure,  15 

in  malpositions  of  the  fetus,  80 

malpresentations   or   malpositions 

of  child,  33 
— • — 'modern,   14 
— ■ — Murphy's   (1862),  13 

non-pelvic,     anteflexion     of     the 

uterus,  59 

^  atresia  of  the  cervix,  58 

atresia  of  the  vagina,  58 

atresia  of  the  vulva,  57 

carcinoma  of  the  cervix,  54 

cicatricial    stenosis   of   cervix, 

58 


204 


INDEX 


Cesarean  section,  indications  for,  non- 
pelvic,  dystocia  following  oper- 
ation for  relief  of  retroposi- 
tions  of  uterus,  60 

echinococcus  cysts,  57 

fibromyomata    of    the    uterus, 

53 

general  considerations,  52 

■^=- ovarian  tumors,  55 

■ — •previous   Cesarian   section,    or 

other  operations  on  the  uterus, 

53,  57,  62 

retroflexion  of  the  uterus,  59 

■ — 'tumors  of  the  bladder,  57 

^  tumors     not     connected     with 

generative  organs,  57 

tumors  of  kidney  or  spleen,  57 

' — 'tumors  of  the  rectum,  57 

'tumors  of  uterus  and  other  pel- 
vic organs,  53 
— • — ■ — ^  tumors  of  the  vagina,  58 

uterine  displacements,  59 

— ■  —  originally  as  a  last  resort,  11 

pelvic,  16 

absolute,  17 

—  contraction  of  pelvic  outlet,  34 

— ■ deformities.,  40 

• — coxalgic  pelvis,  43 

exostoses,  49 

— ■ 'kyphotic  pelvis,  40 

obliquely       contracted,       or 

Nagele  pelvis,  45 

old  pelvic  fractures,  49 

osteomalacic  pelvis,  47 

spondylolisthetic  pelvis,  42 

transversely    contracted,    or 

Robert  pelvis,  47 

tumors,  49 

— ■ disproportion     between      fetal 

head  and  maternal  pelvis,  16, 

17,  181,  183 

examination  for,  25 

factors     to     be     considered 

with,  26 
molding     power     of     fetal 

head,  28 

funnel,  38 

importance  of  pelvic  examina- 
tion   during    last    weeks    of 

pregnancy,  22 

relative,  18 

with  a  true  conjugate  of  more 

'    than  nine  centimeters,  32 


Cesarean  section,  indications  for,  pel- 
vic delivery  impossible  or  dan- 
gerous, 13,  15 

'in  placenta  previa,  71,  184 

in  poor  nervous  equipment,  yy 

— '  — ^  in  poor  physical  equipment,  yy 

— ' — 'postmortem,  81 

in  pre-aseptic  days,  13 

— '  —  in  premature  separation  of  the 
normally  situated  placenta,  73 

— '  —  preservation  of  fetal  life,  15 

to  prevent  pelvic  damage  follow- 
ing operations  for  repair  of 
previous  injury,  79 

in    toxemia    of    pregnancy    and 

eclampsia,  67 

—  indications  for  abdominal  abortion, 

—  indications   for   removal   of   uterus, 

atony,  with  increased  hemor- 
rhage, 145 

— ■ — 'infection,  145 

— '  —  myomata,  145 

'  premature  separation  of  placenta, 

145 

—  in  infected  cases,  choice  of  method, 

^53,  154,  W  187 

hysterectomy  indicated  in,  170 

— '  —  transperitoneal  method  unsuit- 
able to,  170 

—  instruments  employed  in,  100 

—  method  of  procedure,  administration 

of  ergot  or  pituitary  extract, 
or  both,  106 

avoidance  of  haste,  109 

care  of  uterus  before  closing  ab- 
dominal wall,  117 

cervical  dilatation,  116 

'Classical  operation,  100 

— '  —  closure  of  abdominal  wall,  117 

— • — 'Conduct  of  operation,  109 

■  cord,  no 

'  delivery  of  uterus  through  abdom- 
inal wound.  III 

— ■  —  extraction  of  child,   no 

incision  of  abdomen,  high,  108 

■  —  location,  107 

low,  108 

size  of,  108 

incision,    transverse,    of    fundus, 

"3 

incision  of  uterus,  no 

in  lower  uterine  segment,  115 


INDEX 


205 


Cesarean  section,  method  of  procedure, 
incision   of  uterus,    suture  of, 

113 

immediately  following  completed 

operation,  117 

placenta,  no 

removal  of,  113 

'in  presence  of  adhesions,  107 

removal  of  placenta  and  mem- 
branes, 113 

stomach  washing,  117 

■  suture    of    uterine    incision,    112, 

113 

uterine  hemorrhage,  112 

vaginal  preparation,  116 

—  methods  of  procedure,  special,  gen- 

eral considerations,  144 
incision    of    fundus,    transverse, 

113 
removal  of  uterus,  indications  for, 

145 

Porro  operation,  146 

supravaginal         hysterectomy, 

146 
by  total  hysterectomy,  149 

—  modifications  of,  to  eliminate  disad- 

vantages   of    classical    opera- 
tion, 151 

results    from    reported   series   of 

cases,  152 

—  origin  of  term,  i 
— Porro  (1876),  5 
modifications  of,  6 

purpose  and  results  of,  144 

-technic  of,  146 

—  postmortem,  indications  for,  81 
precautions      against      erroneous 

diagnosis  of  death,  82 

—  precluding   future   pelvic   deliveries, 

53,  57,  62 

— ■  preparations  for,  anesthesia.  See 
Anesthesia. 

avoidance  of  vaginal  examina- 
tions, 97 

beginning  of,  97 

of  bowels,  98 

—  —  diet,  97 

^drinking  of  water,  97 

^  in  emergency  cases,  99 

of  field  of  operation,  98 

hypnotic,  98 

immediately  preceding,  99 

instruments  and  sutures,  100 


Cesarean  section,  preparations  for, 
morphin-scopolamin  sequence, 
104 

— ■  —  of  operator  and  assistants,  99 

— ■  —  time  of  operation,  94 

time    of   operation,    before    onset 

of  labor,  advantages  of,  95 

• — in  certain  heart  conditions,  96 

in  late  cases,  96 

— ■ selected  date,  95 

at  time  of  election,  best  results 

obtained  from,  96 

■  —  in  toxemia,  96 

—  in  presence  of  uterine  infection,  to 
be  followed  by  supravaginal 
amputation  of  uterus,  19,  88 

— ^principles  governing  choice  of 
operation,  173,  176 

when  abdominal  operation  is  in- 
advisable,  174 

according  to  estimated  degree  of 

abnormality,   179 

— •  —  in  cases  requiring  examination 
under  anesthesia,  186 

— ■  — ■  depending  on  urgency  of  symp- 
toms, 184 

in  disproportion  in  pelvic  meas- 
urements, 16,  17,  25,  26,  28 

— ■ 'marked,  183 

^  slight,  181  ,     . 

in  doubtful  cases  permitted  to  go 

into  labor,  178,  180,   182,   183 

for  elective  Cesarean  section,  86, 

91,  92,  181 

environment,  177 

^  errors  in  judgment  in,  175 

— " — ■  exhaustion,  1 86 

in  heart  lesions,   184.     See   also 

Cardiac  Complications. 

— ■ — 'importance  of  carefully  super- 
vised labor,  179 

— ■  —  importance  of  prenatal  care,  174 

importance  of  prenatal  study,  152, 

/55 

in  infected  cases,  187 

^when   labor    has    already   begun, 

176 

objects  to  be  sought  in  every  ob- 
stetric case,  173 

-when  patient  is  first  seen  in  la- 
bor, 185 

'in  patient  under  observation  dur- 
ing pregnancy,  177 


206 


INDEX 


Cesarean  section,  principles  governing 
choice  of  operation,  in  pla- 
centa previa,   184 

sterilization,  174.  See  also  Ster- 
ilization at  Time  of  Opera- 
tion. 

summary  of,  188 

—  results    of,    better    when    performed 

early  in  labor,  11 

not  ideal  even  under  best  condi- 
tions, 14 

increased    saifety    under    modern 

conditions,   13 

v^'hen  performed  at  time  of  elec- 
tion rather  than  as  a  secon- 
dary or  late  operation,  14 

—  Sellheim's  operation,  8,  171 

— ■  sterilization  of  patient  at  time  of 
operation.     See  Sterilization. 

—  sutures  employed  in,  100 

—  time  of  operation,  94 
after  onset  of  labor,  97 

before  onset  of  labor,  advantages 

of,  95 

^  in  heart  conditions,  96 

^importance  of  prenatal  examina- 
tions, 94 

late  cases,  96 

in  obstetric  emergencies,  97 

'Seldom    more    than     four    weeks 

from  estimated  date  of  labor, 

97 

—  —  selected  date,  95 

-at   time   of   election,   best   results 

obtained  from,  96 
— ■  —  in  toxemia,  96 

—  transperitoneal,  advantages  of,  over 

true  extraperitoneal  methods, 
167,  169 

—  — ■  Hirst's     modification     of      Veit- 

Fromme  operations,  technic 
of,  164 

as  a  modification  of  Frank's  ex- 
traperitoneal operations,  8 

method  of,   155 

—  —  purpose  of,  151 

results  of,  from  reported  series  of 

cases,  152 
— ■ — 'theory  of,  162 

unsuitable  in  infected  cases,   170 

variations  in,  163 

Veit-Fromme  methods,  165 

objection  to,  166 


Cesarean  section,  vaginal.  See  Va- 
ginal  Hysterotomy. 

—  vaginal  examinations  to  be  avoided 

before,  97 

"Cesones,"  i 

Chloroform,  as  an  anesthetic  in  Cesa- 
rean section,  102 

Complications  of  pregnancy.  See  Preg- 
nancy. 

Coxalgic  pelvis,  43 

Craniotomy,  indications  for,   19,   156 

Dementia,  sterilization  of  patient  at 
time  of  Cesarean  section,  when 
previously  afflicted  with,  142 

Diet,  after  Cesarean  section,  120 

—  preceding  operation,  97 
Dilatability   of   cervix,   as   a  sine   qua 

non  of  successful  pelvic  deliv- 
ery, 26 

Dilatation  of  cervix,  116 

Dilatation  of  stomach,  acute,  as  com- 
plication after  Cesarean  sec- 
tion, 127 

Distention  of  abdomen,  following  Ce- 
sarean section,  122 

Dystocia,  following  operations  for  re- 
lief of  retropositions  of  uterus, 
60 

Echinococcus  cysts,  indicating  Cesa- 
rean section,  57 

Eclampsia,  methods  of  delivery  indi- 
cated, conservative  school,  70 

radical  school,  69 

— ■  prevention  of,  67,  69 

Embolism,  following  Cesarean  section, 
130 

Ergot,  administration  of,  before  in- 
cision for  Cesarean  section,  106 

Ether,  as  an  anesthetic  in  Cesarean  sec- 
tion, 103 

Exhaustion,  as  a  contra-indication  to 
elective  Cesarean  section,  89 

— •  general,  89 

—  of  the  uterus,  89 
Exostoses,  pelvic,  49 

Fetal  head,  disproportion  between  ma- 
ternal pelvis  and,   16 
— '  molding  power  of,  28 
Fetus,  malpositions  of,  33 
breech  presentations,  80 


INDEX 


207 


Fetus,  malpositions  of,  face  presenta- 
tions, 81 
— •  —  transverse  presentations,  8r 
Fibromyomata  of  the   uterus,   indicat- 
ing Cesarean  section,  53 
Fractures,  pelvic,  49 
Frank's   operation    (1907),   7 
— ■  modifications  of,  8 

Gas-oxygen,  as  an  anesthetic  in  Cesa- 
rean section,  103 

Hemorrhage,  during  pregnancy,  exter- 
nal, 73 

— • — 'Uterine,  71,  72 

Hirst's  operation,  technic  of,  164 

Hysterectomy,  indications  for,  in  car- 
cinoma of  the  cervix  compli- 
cating pregnancy,  54 

—  following   Cesarean   section,   indica- 

tions for,  19 

—  indicated  in  infected  cases,   170 

—  Sellheim's  operation  substituted  for, 

171 

—  supra-vaginal,  146 

—  total,  149 

^indication  for,  156 

Hysterotomy,  vaginal.  See  Vaginal 
Hysterotomy. 

Incision,  abdominal,  high,  108 
— • — 'location  of,  107 
— •  —  low,  108 
size  of,  108 

—  transverse,  of  fundus,  113 
— '  uterine,  no 

in  lower  uterine  segment,  115 

suture  of,  113 

Infected  cases,  extraperitoneal  and 
transperitoneal  Cesarean  sec- 
tion unsuitable  in,  170 

—  hysterectomy  indicated  in,  170 

—  method  of  procedure  in,   187,  188 

—  removal  of  uterus  indicated  in,  145 

—  Sellheim's  operation  indicated  in,  171 

—  transperitoneal     method     unsuitable 

in,  T70 

—  See  also  Uterine  Infection. 
Instruments     employed     in     Cesarean 

section,  100 

Kidney,  tumors  of,  indicating  Cesarean 
section,  57 


Kronig's  operation,  9 
Kiistner's  operation,  9 

—  disadvantages  of,  160 
— ■  reports  on,  153 

—  technique  of,  157 
Kyphotic  pelvis,  40 

Labor,  probable  character  of,  26 

—  probable  effect  of,  on  patient.  30 

—  results  of,  in  kyphotic  pelves,  41 

in  old  pelvic  fractures,  50 

in  spondylolisthetic  pelves,  42 

Lactation,      after     Cesarean     section, 

124 

Laparo-elytrotomy,  performed  by  Do- 
derlein,  8 

Laparohysterotomy.  See  Cesarean  Sec- 
tion, 

Laparotomy,  indications  for,  in  car- 
diac lesions,  83 

in  ovarian  tumors,  56 

Latzko's  operation,  8 

—  technique  of,  161 

Lochia,  retention  of,  following  Cesa- 
rean section,  treatment  of,  123 

Molding  power  of  fetal  head,  28 
Morphin-scopolamin  sequence,  104 
Murphy's  indications  for  Cesarean  sec- 
tion, 13 
Myocarditis,   indicating   Cesarean   sec- 
tion, 76 
Myomata,  as  an  indication  for  removal 
of  uterus,  145 

Nagele  pelvis,  45 

Nephritis,  chronic,  indicating  abdom- 
inal abortion,  83 

sterilization  of  patient  at  time  of 

Cesarean  section  in  advanced 
cases  of,  141 

—  unfavorable  prognosis  for  Cesarean 

section  in  presence  of,  91 
Nitrous  oxide  gas,  as  an  anesthetic  in 

Cesarean  section,  102 
Novocain,      as     local     anesthesia     in 

Cesarean  section,  103 

Obstetrics,  choice  of  operation,  accord- 
ing to  estimated  degree  of  ab- 
normality, 179 

doubtful    cases    permitted    to    go 

into  labor,  180 


208 


INDEX 


Obstetrics,  choice  of  operation,  when 
patient  is  first  seen   in  labor, 

summary  of  principles  of,  i88 

—  doubtful  cases  permitted  to  go  into 

labor,  182,  183 

—  errors  in  judgment  in,  175 

—  importance   of   carefully   supervised 

labor,  179 

of  prenatal  care  in,  174 

of  prenatal  examinations,  94 

'Of  prenatal  study,  152,  155 

—  patients  to  be  considered  as  possibly 

abnormal    till    proved    other- 
wise, 178 

—  objects  to  be  sought  in,  173 
Organic    disease,    sterilization    of    pa- 
tient at  time  of  Cesarean  sec- 
tion in,  141 

Osteomalacic  pelvis,  47 

Ovarian   tumors,    indicating    Cesarean 

section,  55 
— ■  indicating  laparotomy,  56 
Ovariotomy,  as  method  of  sterilization, 

142 

Pain,  following  Cesarean  section,  119 
Panhysterectomy,    first    performed    by 

Bischoff,  6 
Paravertebral  anesthesia,   104 
Pelvic  contraction,  as  an  indication  for 

Cesarean  section,  17 
— 'moderate,  32 

—  oblique,  or  Nagele  pelvis,  45 

due  to  hip  disease  in  early  life, 

43 

—  of  outlet,  34 

—  transverse,  or  Robert  pelvis,  47 
Pelvic  deformities,  indicating  Cesarean 

section,  40 

coxalgic  pelvis,  43 

'exostoses,  49 

kyphotic  pelvis,  40 

obliquely   contracted,   or   Nagele 

pelvis,  45 

old  pelvic  fractures,  49 

osteomalacic  pelvis,  47 

spondylolisthetic  pelvis,  42 

transversely  contracted,  or  Rob- 
ert pelvis,  47 

tumors,  49 

Pelvic  examination,  for  indications  for 
Cesarean  section,  22 


Pelvic  exostoses,  49 
Pelvic   fractures,   49 
Pelvic    indications    for    Cesarean   sec- 
tion, absolute,  17 

—  relative,   18 

—  See  also  Cesarean  Section,  Indica- 

tions for.  Pelvic. 
Pelvic  measurements,  Williams',  35 
Pelvic  outlet,   contraction   of,  34 
Pelvic  tumors,  49 
Pelvis,  coxalgic,  43 

—  disproportion  between  head  of  child 

and,  16 

—  funnel,  in  young  and  elderly  primi- 

parae,      indicating      Cesarean 
section,  38 

—  indications     for     Cesarean     section 

based   on  study  of,    16.     See 
also  Cesarean  Section,  indica- 
tions for,  Pelvic. 
— ■  kyphotic,  40 

—  obliquely  contracted,  or  Nagele,  45 

—  Nagele,  or  obliquely  contracted,  45 
— '  osteomalacic,  47 

— '  Robert,   or  transversely   contracted, 

47  _ 

—  syondylolisthetic,  42 

—  transversely    contracted,   or    Robert 

pelvis,  47 

—  with  true  conjugate   of  more  than 

nine  centimeters,  32 

Peritonitis,  septic,  following  Cesarean 
section.    See  Septic  Peritonitis. 

Pituitary  extract,  administration  of,  be- 
fore incision  for  Cesarean  sec- 
tion, 106 

Placenta,  premature  separation  of,  73 

as  an  indication  for  removal  of 

uterus,  145 

treatment  for,  74 

—  procedure    with,    in    Cesarean    sec- 

tion, no 

removal  of,  113 

Placenta  previa,  importance  of  prompt 

diagnosis  and  treatment  of,  71, 

J2 

—  indicating  Cesarean  section,  184 

—  methods  of  treatment,  y^ 
Pneumonia,    following    Cesarean    sec- 
tion, 129 

Porro's  operation  (1876),  5 

—  description  of,  146 

—  modifications  of,  6 


INDEX 


209 


Porro's  operation  (1876),  purpose  and 
results  of,  144 

Postmorten  Cesarean  section,  81 

Pregnancy,  complications  of,  carcino- 
ma of  the  cervix,  54 

— ■  —  cardiac,  74,  96,  184 

indicating  abdomjnal  abortion, 

myocarditis,  76 

valvular  lesions,  75 

fibromyomata  of  the  uterus,  53 

ovarian  tumors,  55 

placenta  previa,  71 

— . —  premature  separation  of  normally 

situated  placenta,  73 
Pregnancy,    complications   of,   toxemia 

and  eclampsia,  67,  90,  96 
Premature   separation   of  placenta,   as 

an  indication   for   removal  of 

uterus,  145 
Pubiotomy,   indications  for,   157 
Pulse,  after  Cesarean  section,  126 

Rectum,  tumors  of,  indicating  Cesarean 

section,  57 
Removal    of    uterus,    indications    for, 

145 
at  time  of  Cesarean  section,  145 

—  Porro  operation,  146 

—  supra-vaginal  hysterectomy,  146 

—  total  hysterectomy,  149 
Retroflexion  of  the  uterus,  indicating 

Cesarean  section,  59 
Retropositions  of  uterus,  dystocia  fol- 

low^ing    operations    for    relief 

of,  60 
Robert  pelvis,  47 

Sanger's  operation  (1882),  61 

—  succeeding     the     Porro     operation, 

144 
Sellheim's  operation,  8 

—  disadvantages  of,  171 

—  substituted  for  hysterectomy,  171 

—  technic  of,  171 

Septic  complications  following  Cesa- 
rean section,  130 

Septic  peritonitis,  complicating  con- 
valescence, 134 

sources  of,  134 

symptoms  of,  135 

treatment  of,  136 

Spinal  anesthesia,  104 


Spleen,  tumors  of,  indicating  Cesarean 

section,  57 
Spondylolisthetic  pelvis,  42 
Sterilization,  deferred,  174 

—  of  patient  at  time  of  operation,  ad- 

visability of,  139 
as   against   continence  of  patient 

and  husband,  143 

at  first  Cesarean  section,  139 

indications  for,   139-142 

indications  for  removal  of  uterus, 

145 

methods  of,  142 

double  ligation  of  tubes,  w^ith 

division  between  the  ligatures, 
142 

■  —  excision   of  proximal  ends   of 

tubes  from  cornua  of  uterus 
by   V-shaped   incisions,    143 

inversion  of  fibriated  extremi- 
ties of  tubes  and  closure  of 
outer  ends  by  suture,  142 

removal  of  ovaries,  142 

supravaginal     amputation     of 

body  of  uterus,  142 

in    patients    who    have    suffered 

from  dementia,  142 

in    presence    of    cardiac   disease, 

140,  141 

■  —  of  chronic  nephritis,  141 

of  conditions  rendering  future 

pregnancies  dangerous,  140 

of     organic     disease,     where 

future  pregnancy  is  a  menace, 
141 

by  removal  of  uterus,  indications 

for,  145 

general  considerations,  144 

— ■  — •  — ■  Porro  operation,  146 

supravaginal         hysterectomy, 

146 

total  hysterectomy,  149 

at      second      Cesarean      section, 

140 

Stomach  washing,  after  Cesarean  sec- 
tion, 117 

Supravaginal  amputation  of  uterus,  fol- 
lowing Cesarean  section,  19, 
88 

—  indications  for,  156 

—  as  method  of  sterilization,  142 

—  See    also     Supravaginal    Hysterec- 

tomy. 


210 


INBEX 


Supravaginal  hysterectomy,  description 
of,  146-149.  See  also  Supra- 
vaginal Amputation  of  Uterus. 

Sutures,  employed  in  Cesarean  section, 
100 

—  of  uterine  incision,   113 

Temperature,    after    Cesarean   section, 

125 

Thirst,  follovi^ing  Cesarean  section,  120 

Toxemia  of  pregnancy  and  eclampsia, 
contra-indications  to  elective 
Cesarean   section  in,   90 

— 'methods  of  delivery  indicated  in, 
68 

— •  prevention  of,  67 

— '  time  of  election  for  Cesarean  sec- 
tion in  presence  of,  96 

—  two     important    objects     sought    in 

treatment  of,  90 
Tumors  of  the  bladder,  indicating  Cesa- 
rean section,  57 

—  of  kidney  or  spleen,  indicating  Cesa- 

rean section,  57 

—  of  the  ovaries,  indicating  Cesarean 

section,  55 
— • — ^indicating  laparotomy,  56 
— 'Of  the  pelvis,  49 

—  of  the  rectum,   indicating   Cesarean 

section,  57 

—  of  uterus  and  other  pelvic  organs, 

indicating    Cesarean    section, 

53 

— carcinoma  of  the  cervix,  54 

— fibromyomata  of  uterus,  53 

• — ^  ovarian  tumors,  55 

—  of  the   vagina,   indicating   Cesarean 

section,  58 
Uterine  displacements,  dystocia  follow- 
ing   operations    for    relief   of, 
60 

—  indicating    Cesarean    section,    ante- 

flexion, 59 

'retroflexion,  59 

Uterine  hemorrhage,  during  latter  half 
of  pregnancy,  prompt  diagno- 
sis of,  and  methods  of  treat- 
ment, 72 

Uterine  infection,  attempts  to  induce  la- 
bor by  bag  or  bougie,  or  at- 
tempts at  pelvic  delivery  pre- 
disposing to,  89 


Uterine  infection,  Cesarean  section  as 
only  available  means  of  de- 
livery, procedure  following, 
88 

—  Cesarean  section  contra-indicated  in, 

87 

—  premature    rupture    of    membranes 

predisposing  to,  88 

—  repeated  examinations  during  labor 

predisposing  to,  88 

—  See  also  Infected  cases. 

Uterus,  indications  for  removal  of,  145 

—  removal  of.    See  Removal  of  Uterus. 

—  tumors  of,  indicating  Cesarean  sec- 

tion,  53 

carcinoma  of  the  cervix,  54 

^  fibromyomata,  53 

Vagina,  atresia  of,  indicating  Cesarean 

section,  58 

—  tumors  of,  indicating  Cesarean  sec- 

tion, 58 
Vaginal   examinations,   to   be   avoided 
preceding     Cesarean     section, 

97 
Vaginal    hysterotomy,    description    of, 
190 

—  difficulties  of,  199 

—  history  of,  193 

—  increased  difficulty  of,  the  nearer  to 

term,  193 

— 'indications  for,  190 

in  early  pregnancy,  191 

^  during  last  three  months  of  preg- 
nancy, 192 

'  during    middle    three    months   of 

pregnancy,  192 

in  primiparae,  191 

rigidity  of  cervix,  191 

—  technic  of,  193 

precautions  to  be  observed,   197, 

198 

— ^  terminology  of,  190 

Vaginal  preparation  in  Cesarean  sec- 
tion, 116 

Veit-Fromme  operations,  165 

—  disadvantage  of,   166 

Vulva,  atresia  of,  indicating  Cesarean 
section,  57 


Wound  infection,  complicating  conva- 
lescence, 136 

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